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PARACENTESIS 


THE    PERICARDIUM. 


PARACENTESIS 


OP 


THE    PEEICAEDIITM, 


A   CONSIDERATION    OP    THE 


SURGICAL    TREATMENT 


OF 


PERICARDIAL  EFFUSIONS. 


BY 

JOHN   B.  ROBERTS,  A.M.,  M.D., 

LECTVRER     ON     ANATOMY     IN     THE     PHILADELPHIA     SCHOOL     OF     ANATOMY;     DEMONSTRATOR     OF 

ANATOJttY   IN   THE   PHILADELPHIA   DENTAL   COLLEGE;    FELLOW   OP  THE 

PHILADELPHIA  ACADEMY   OF  SURGERY. 


WITH    ILLUSTRATIONS. 


PH ILADELPH I A  : 

J.    B.    LIPPINCOTT    &    CO. 

London  :    16  Southampton  Street,  Covent  Garden. 
188  0. 


Copyright,  1879,  by  John  B.  Roberts,  M.D. 


PREFACE. 


Several  years  ago,  while  resident  physician  and  sur- 
geon in  one  of  the  hospitals  of  Philadelphia,  I  endeavored 
to  occupy  my  spare  hours  profitably  in  the  library  of  the 
institution.  Among  the  subjects  that  attracted  my  atten- 
tion was  that  of  tapping  the  pericardium.  Although  I 
found  recorded  a  number  of  isolated  instances  of  the 
operation,  there  were  few  general  deductions  made,  and 
there  existed  no  complete  collection  of  cases  from  which 
statistical  information  could  be  obtained.  I  accordingly 
published  a  short  journal  article  on  the  subject.  Since 
that  period  my  interest  in  the  operation  has  not  abated, 
and  I  have  read  with  avidity  whatever  has  come  to  my 
notice  on  the  subject ;  moreover,  the  opportunities  fur- 
nished in  the  dead-rooms  of  the  Pennsylvania  Hospital 
and  of  the  Philadelphia  School  of  Anatomy  have  enabled 
me  to  study  the  anatomical  relations  of  the  parts  con- 
cerned. There  is,  so  far  as  known  to  me,  no  volume 
published,  and  very  little  contained  in  the  text-books,  on 
this  subject ;  hence  I  have  ventured  to  offer  to  the  pro- 
fession this  monograph  on  Paracentesis  of  the  Peri- 
cardium, hoping  that,  as  it  has  no  rival,  its  deficiencies 
may  not  be  apparent. 

J.  B.  R. 

1118  Arch  Street,  November,  1879. 


OOTsTTENTS. 


CHAPTER    I. 

PAOE 

Causes  or  Pericardial  Effusions 9 

Varieties  of  Fluid  Effused 12 

Quantity  of  Fluid 14 


CHAPTER    II. 

Symptoms  of  Pericardial  Effusion 17 

Physical  Signs 20 

DiAGjs'osis 29 

Prognosis 34 

CHAPTER   III. 

Treatment 36 

hlstortt  of  the  operation 88 

Anatomy  of  the  Parts  Concerned 40 

Cases  Suitable  for  Operation 44 


CHAPTER    IV. 

Methods  of  Operating 49 

Point  of  Puncture 58 

7 


CONTENTS. 
CHAPTER  V. 


PAGE 

71 


Dangers  to  be  Encountered  

Objections  to  the  Operation '^'^ 

Treatment  of  Complications ^^ 


CHAPTER   VI. 


Table  of  Cases 

Results  of  the  Operation 


84 
94 


PARACENTESIS  OF  THE  PERICARDIUM. 


CHAPTER  I. 


THE    CAUSES    OE   PERICARDIAL    EFFUSIONS. 

In  order  to  discuss  properly  any  method  of  treating  dis- 
ease, it  becomes  necessary  to  direct  attention  at  first  to  the 
etiology,  symptomatology,  and  diagnosis  of  the  aftection 
in  question.  It  is  therefore  proper  to  devote  at  first  some 
time  to  the  consideration  of  the  conditions  that  give  rise 
to  pericardial  efl:usions.  Every  one  has  seen  cases  where 
the  autopsy  revealed  a  few  drachms  of  serum  in  the  peri- 
cardial sac  without  there  having  been  any  cardiac  trouble. 
This  fluid  is  a  transudation  that  has  occurred  just  at  the 
time  of  death,  or  subsequent  to  that  event,  coming  from 
the  coronary  and  pericardial  veins,  and  possibly  the  heart 
itself,  but  has  not  been  present  as  a  distinct  ante-mortem 
condition.  This  must  not  be  confounded  with  pathologi- 
cal changes,  but  is  to  be  regarded  as  a  post-mortem  ap- 
pearance, even  though  at  times  as  much  as  three  ounces* 
of  serum  is  found.  When  death  has  occurred  from  dis- 
ease involving  great  venous  stasis  of  the  coronary  vessels 
the  quantity  of  pericardial  fluid  found  at  the  autopsy  is 


*  Ziemssen's  Cyclopjedia  of  Medicine,  vi.  p.  665. 
2 


10  PARACENTESIS  OF  THE  PERICARDIUM. 

more  apt  to  be  great ;  in  which  cases  it  becomes  essential 
that  the  examiner  discriminate  between  effusions  taking 
place  before  and  after  dissolution. 

The  two  great  causes  of  pericardial  effusions  happening 
during  life  are  of  course  inflammation  of  the  serous  mem- 
brane, and  those  conditions  Avhich  lead  to  a  transudation 
of  the  blood  elements  into  the  cellular  tissue,  and  into  the 
various  cavities  of  the  body.  The  former  will  furnish 
plastic  matter  and  serum  in  varying  proportions  accord- 
ing to  the  character  of  the  inflammatory  action,  while  the 
latter  will  give  rise  to  collections  of  serum  or  blood,  either 
separately  or  mingled.  In  the  former  case  there  will  at 
times  be  a  certain  amount  of  coloring  matter  tinging  the 
fluid,  because  of  the  rupture  of  some  small  capillary 
vessels.  In  either  case  the  effusion  may  become  purulent 
in  character  secondarily,  but  rarely,  if  ever,  is  the  effusion 
purulent  at  the  beginning.  Under  these  two  heads  there 
are  many  causes  which  are  operative  in  inducing  collec- 
tions of  fluid  in  the  pericardium.  Thus  the  pericarditis 
may  be  idiopathic,  which,  however,  is  doubted  by  many, 
it  may  be  traumatic,  or  it  may  occur  as  a  secondary  affec- 
tion. Secondary  pericarditis  is  frequently  due  to  acute 
articular  rheumatism,  chronic  nephritis,  pyaemia,  scarla- 
tina, and  other  exanthematous  diseases.  It  may,  also,  as 
is  readily  appreciated,  be  the  result  of  inflammation  of 
the  pleura  or  lungs,  which  structures,  on  account  of  their 
proximity  to  the  pericardium,  may  act  as  the  starting-point 
of  the  process  giving  rise  to  the  pericardial  effusion.  In 
"  Ziemssen's  Cyclopaedia  of  Medicine,"  the  occurrence  of 
pneumonia  and  pericarditis  together  is  dwelt  upon  at  con- 
siderable length. 

Pericardial  effusion  is  said  to  occur  only  in  rare  in- 
stances after  wounds  of  the  sac  and  heart ;  whether  this  is 
a  true  statement  of  the  case,  or  whether  it  depends  upon 


CAUSES   OF  PERICARDIAL   EFFUSIONS.  H 

the  circumstance  that  patients  with  such  injuries  are  apt 
to  die  early,  I  am  not  prepared  to  say. 

Under  the  second  class  of  conditions  giving  rise  to  effu- 
sions into  the  pericardial  sac  may  be  mentioned  those  dis- 
eases, which  cause  dropsy  of  the  other  serous  cavities  from 
transudation  of  serum, ^such  as  hepatic,  renal,  and  perhaps 
even  cardiac  affections.  Pathological  blood  changes  also 
may  give  rise  to  effusion,  as  is  seen  in  cases  of  purpura 
and  scurvy,  where  hemorrhage  takes  place  and  haemo-peri- 
cardium  results.     Such  were  Kyber's  cases. 

The  result  in  most  instances  of  pericarditis  is  that  ab- 
sorption of  the  fluid  occurs,  and  the  patient  suffers  little 
subsequent  trouble,  except  there  be  considerable  adhesion 
of  parietal  and  visceral  layer.  Hence  it  is  that  but  rarely 
does  the  effusion  of  rheumatic  pericarditis  increase  to  an 
amount  sufficient  to  call  for  operative  treatment.  It  does 
happen,  occasionally,  however,  that  the  inflammation  be- 
comes chronic,  the  effusion  augmented,  and  the  sac  more 
and  more  distended,  until  death  results  from  mechanical 
causes.  Such  cases  must  certainly  be  most  amenable  to 
cure  by  relieving  the  distended  pericardium,  and  the 
statistics  of  the  operation  of  tapping  show  this  to  be  the 
fact.  The  inflammatory  fluids  furnished  in  idiopathic, 
traumatic,  and  other  cases  where  there  is  a  tendency  to 
recovery,  as  far  as  the  lesion  is  concerned,  will  probably 
be  absorbed  in  a  similar  manner.  The  effusions  due  to 
profound  blood  alteration,  and  to  a  general  dropsical  or 
anasarcous  condition,  must  be  understood  as  belonging  to 
a  different  category  of  causation.  I  should  prefer  to  at- 
tribute these  to  a  process  of  filtration,  by  which  the  blood 
elements  escape,  than  to  a  determinate  variety  of  inflam- 
mation, though  some  may  feel  inclined  to  say  there  is 
always  some  pericardial  inflammation  present  even  from 
the  first. 


12  PARACENTESIS  OF   THE   PERICARDIUM. 

Iiitra-thoracic  growths  may  be  instrumental  in  pro- 
ducing effusion,  either  by  instituting  inflammatory  pro- 
cesses by  reason  of  their  contiguity  to  the  pericardium,  or 
on  account  of  emptying  their  contents  into  the  sac,  or  by 
interference  with  the  neighboring  circulation  due  to  press- 
ure. Under  this  head  should  be  placed  cases  of  hydatid 
and  cancerous  tumors  of  the  mediastinum,  which  have 
been  known  to  implicate  the  pericardium.  Hydro-peri- 
cardium has  also  been  known  to  occur  from  mechanical 
causes,  such  as  pressure  of  an  aneurism,  disease  of  the 
cardiac  veins,  their  obstruction  by  a  clot,  or  from  sudden 
extreme  pneumothorax. 

So,  again,  an  abscess  or  a  collection  of  pus  in  the  pleural 
cavity  may  find  its  way  into  the  pericardium  by  erosion  of 
the  wall  of  the  sac.  A  very  interesting  case  was  seen  by 
me  some  years  ago,  where  a  patch  of  disease  in  the  aorta 
allowed  the  wall  to  give  way,  so  that  the  blood  escaped 
somewhat  slowly  into  the  pericardium.  This  case  proved 
fatal  of  course,  and  was  only  understood  after  the  autopsy 
had  been  made,  when  a  large  amount  of  blood  was  found 
in  the  pericardial  cavity. 

THE   VARIETIES    OF   FLUIDS    EFFUSED. 

The  character  of  the  fluid  contained  in  the  pericardium 
must  vary  with  the  cause  which  induces  its  presence.  In 
general  dropsy  due  to  hepatic  or  renal  disease  one  expects 
to  find  serum  alone,  but  if  the  eftusion  owe  its  origin  to 
inflammation,  there  will  be  more  or  less  fibrin  intermingled 
with  the  serous  fluid  contained  in  the  cavity.  This  is  at 
times  very  small  in  quantity,  while  in  other  instances  the 
inflammatory  process  is  plastic  in  character  and  very  little 
serum  is  found,  though  the  layers  of  pericardium  are  ren- 
dered rough  and  shaggy,  with  an  abundant  deposit  of  in- 
flammatory lymph  upon  the  whole  of  their  surfaces.    "With 


VARIETIES  OF  FLUIDS  EFFUSED.  13 

such  cases  we  have  nothing  to  do  in  the  present  treatise. 
Sometimes  there  may  be  a  small  quantity  of  blood  con- 
tained in  this  complex  fluid,  due  to  rupture  of  capillaries, 
which  have  perhaps  been  developed  in  the  adhesions  formed 
during  the  early  stages  or  days  of  the  pericarditis. 

In  certain  instances  of  purpura  and  scorbutus,  blood  is 
exuded  here  as  in  other  situations,  and  the  pericardial 
cavity  becomes  distended  with  pure  blood.  This  is  not 
very  frequently  observed  even  in  these  blood  diseases, 
though  Bauer  states*  that  he  has  seen  it  happen  in  other- 
wise healthy  people,  especially  in  chronic  pericarditis  and 
where  the  patients  were  subjects  of  chronic  alcoholism. 
Cancer  may  cause  hemorrhagic  pericarditis,  but  the  con- 
dition is  very  rare.  Many  cases  of  so-called  hemorrhagic 
pericarditis  are  only  instances  of  blood-stained  serous 
effusion.  If  an  adjacent  abscess  bursts  into  the  pericardial 
cavity,  or  a  hydatid  cyst  is  discharged  in  that  direction, 
the  contents  discovered  when  the  sac  is  examined  will  par- 
take of  the  characteristics  of  the  fluids  belonging  to  these 
respective  conditions.  Pus  may  result  secondarily  from 
any  of  these  effusions,  but  it  is  not  likely  that  purulent 
pericarditis  ever  occurs  as  a  primary  condition.  That  ad- 
mission of  air  to  the  interior  of  the  sac  will  induce  suppu- 
ration is  not  to  be  questioned.  ^  In  Chairou's  case,  the 
autopsy  showed  the  existence  of  pus,  though  at  the  time  of 
operation  the  fluid  withdrawn  was  serous.  It  has  been 
stated  that  the  pus  is  not  apt  to  find  its  way  through  the 
overlying  tissues  to  the  exterior  of  the  body,  but  analogy 
would  certainly  lead  us  to  expect  that  purulent  pericarditis 
would  evacuate  itself  in  a  way  similar  to  that  occurring  in 
purulent  collections  in  the  cavity  of  the  pleura.  It  is  prob- 
able that  the  infrequency  of  this  pathological  sequence  in 

*  Ziemssen's  Cyclopaedia,  vi.  p.  563. 


14  PARACENTESIS  OF   THE  PEIUCARDIUM. 

the  former  disease  is  due  to  the  infrequency  of  purulent 
pericarditis  as  an  affection,  and  the  liability  of  death  to 
take  place  in  its  early  stages.  Wyss  is  said*  to  have  re- 
corded an  instance  where  a  rib  was  worn  away  and  a  fis- 
tula established  which  remained  patulous  for  many  years. 
The  discharge  might  take  place  into  the  pleural  cavity, 
bronchi,  or  oesophagus,  if  the  patient  survived  long  enough. 
At  least  there  seems  no  pathological  reason  to  the  contrary. 
It  is  possible  that  both  hemorrhagic  and  purulent  exuda- 
tions may  become  absorbed,  though  this  result  in  the  latter 
case  is  undoubtedly  to  be  regarded  as  very  exceptional. 

QUANTITY    OF    FLUID. 

The  amount  of  the  pericardial  fluid  is  a  matter  of  major 
importance,  for  it  is  owing  to  this  factor  that  there  comes 
in  certain  cases  a  question  of  operation.  In  some  in- 
stances there  is  only  sufiicient  exudation  to  cause  the  two 
serous  layers  to  adhere  slightly.  This  has  been  called  dry 
pericarditis,  but  with  such  cases  we  have  nothing  to  do. 
When  the  inflammation  has  existed  for  some  time  the 
serous  effusion  increases  with  greater  or  less  rapidity; 
and,  if  the  case  become  one  of  chronic  pericarditis,  where 
there  is  no  tendency  of  the  absorbents  to  carry  off  the 
inflammatory  products,  the  sac  may  become  enormously 
distended  until  the  lungs  are  pushed  backwards  and  lat- 
erally, and  the  diaphragm  depressed  until  the  abdominal 
viscera  are  actually  displaced.  As  stated  above,  it  is  usual 
to  find  a  small  amount  of  serum  in  the  pericardium  as  the 
result  of  post-mortem  changes,  but  in  occasional  instances 
of  inflammation  or  dropsy  the  quantity  is  really  astonish- 
ing. Corvisart  mentions  an  instance  where  eight  pounds 
of  serum  were  found.     Andral  givesf  a  case  where  two 

*  Ziemssen,  vi.  p.  564. 

I  Cliniqiie  Med. ,  2d  ed. ,  1829,  vol.  i.,  observ.  iii.  p.  15.  Quoted  by  Hayden. 


qUANTITY  OF  FLUID.  15 

pounds  of  blood  were  discovered  in  this  situation.  Re- 
cently, Dr.  Alonzo  Clark,  of  ]N"ew  York,  has  related*  the 
history-  of  a  patient,  in  whose  pericardium  was  contained 
one  gallon  of  sero-purulent  fluid.  Viry  found  at  the  au- 
tops}'  of  his  case  (ISTo.  55)  that  the  capacity  of  the  sac  was 
two  or  three  litres,  and  that  there  was  on  each  side  a  sort 
of  cul-de-sac,  which  was  on  a  lower  plane  than  the  central 
part  of  the  pericardial  cavity.  In  cases  of  this  kind  it 
would  be  difficult  to  get  the  fluid  to  flow  from  the  trocar. 
A  case  of  purulent  pericarditis  is  recorded,t  where  the 
tension  of  the  distended  sac  was  so  great  that  a  puncture, 
made  at  the  post-mortem  examination,  caused  the  pus  to 
spurt  up  to  the  ceiling.  In  this  patient  there  was  an  ac- 
companying empyema. '  Dieulafoy  states  that  the  pericar- 
dium of  a  well-grown  adult  can  contain  one  thousand  to 
twelve  hundred  grammes  of  water,  and  that  the  sac  when 
injected  overlaps  the  left  edge  of  the  sternum  from  seven 
to  twelve  centimetres.  The  pericardium  of  an  adult  male 
with.a  normal-sized  heart  is  capable,  according  to  Sibson,| 
of  holding  from  fourteen  to  twenty-two  ounces  of  water, 
while  that  of  a  boy  of  six  to  nine  years  can  contain  about 
six  ounces. 

Under  the  influence  of  the  pressure  exerted  by  the  quan- 
tities observed,  as  mentioned  above,  the  pericardial  sac 
becomes  greatly  distended  and  At  times  thinned,  though 
the  irritation  is  more  apt  to  give  rise  to  such  inflammatory 
proliferation  that  the  walls  are  thickened.  When  the 
effusion  is  great,  it  is  usual  to  find  at  the  autopsy  that  the 
heart  lies  at  the  back  and  upper  part  of  the  sac,  as  would 
be  supposed  from  the  attachments  of  the  organ,  and  the 
fact  that  it  is  heavier  than  the  fluid. 


*  Phila.  Med.  Times,  Nov.  9,  1878,  p.  60. 

t  Lancet,  1863,  vol.  ii.  p.  160. 

X  Keynolds's  System  of  Medicine,  vol.  iv.  p.  305. 


16  PARACENTESIS  OF   THE  PERICARDIUM. 

In  a  surgical  view  the  discussion  of  the  amount  of  effu- 
sion deserves  considerable  attention,  for  as  no  one  would 
think  of  tapping  when  the  fluid  is  small  in  quantity,  so, 
on  the  other  hand,  no  good  surgeon  should  hesitate  to  tap 
promptly  when  the  amount  of  serum  or  pus  is  great  and 
threatening  the  existence  of  the  individual.  It  is  to  be 
understood,  however,  that  the  absolute  quantity  would 
not  be  a  certain  guide  even  if  there  was  any  method  of 
calculating  it.  The  parts  can  and  will  accommodate  them- 
selves to  a  large  exudation  of  slow  formation,  while  a 
rapid  accumulation,  though  comparatively  small,  will  in- 
duce the  most  urgent  symptoms.  To  rather  large  effusions 
of  serum  in  this  situation  the  term  hydrops  pericardii  or 
hydro-pericardium  has  been  applied,  and  this  term,  ac- 
cording to  Corvisart,  is  to  be  used  respecting  cases  where 
the  amount  exceeds  six  ounces.  The  nomenclature  I 
should  prefer  would  differ  in  this  respect :  that,  leaving 
quantity  out  of  consideration,  I  should  call  all  effusions 
hydro-pericardium  in  which  the  fluid  is  the  result  of  un- 
balanced circulation  allowing  transudation,  such  as  occurs 
in  obstruction  of  the  venous  circulation  from  any  cause. 
To  cases  of  inflammation,  of  subacute  or  chronic  kind, 
where  there  is  fluid  thrown  out,  the  term  pericarditis,  with 
some  descriptive  adjective,  is  certainly  preferable,  and 
withal  more  scientific  than  hydro-pericardium.  In  a  simi- 
lar manner  if  blood  were  extravasated  into  the  pericardium 
by  a  simple  osmosis  induced  by  profound  blood  alterations, 
the  term  hsemo-pericardium  would  be  proper,  whereas,  if 
the  blood  were  furnished  by  rupture  of  vessels  in  a  state 
of  inflammation,  hemorrhagic  pericarditis  would  be  better. 
According  to  this  nomenclature,  the  appellation  traumatic 
hydro-pericardium  would  not  be  admissible,  but  traumatic 
pericarditis  with  effusion  would  be  legitimate. 


SYMPTOMS   OF  PERICARDIAL  EFFUSION.  ]7 


CHAPTER    11. 

THE    SYMPTOMS    OF    PERICAKDIAL    EFFUSION. 

The  symptoms  of  the  condition  must  next  claim  con- 
siderable attention,  because  the  latent  character  of  diseases 
affecting  the  internal  organs  is  at  times  sufficient  to  throw 
the  attendant  off  the  track.  Again,  the  early  recognition 
of  symptoms,  pointing  to  involvement  of  the  pericardium 
as  a  sequence  of  other  affections,  will  possibly  enable  us 
to  institute  a  line  of  treatment  to  preclude  the  occurrence 
of  large  pericardial  exudation.  It  may  be  stated  in  ad- 
vance that  the  symptoms  alone  of  pericardial  effusion  are 
not  sufficiently  definite  to  permit  a  diagnosis  to  be  made 
without  the  aid  of  physical  examination.  In  fact,  it  was 
this  circumstance  that  deterred  the  earlier  surgeons  from 
attempting  operative  measures.  The  case  did  not  warrant 
the  performance  of  an  operation  until  the  existence  of 
fluid  was  determined;  but  the  presence  of  fluid  could 
seldom  be  more  than  surmised  until  a  knowledge  of  the 
methods  of  physical  exploration  *  was  possessed  by  the 
medical  world. 

In  pericarditis  there  is  at  times  of  course  some  subjective 
evidence  of  trouble  before  the  sero-fibrinous  exudation 
occurs;  but  in  true  hydro-pericardium,  as  we  employ  the 
term,  the  effusion  is  the  first  step  in  the  history  of  the 
condition.  After  the  advent  of  effusion,  the  symptoms 
and  signs  are  similar  without  reference  to  etiolog}'. 

The  symptoms  of  pericarditis  are,  as  a  rule,  obscured 
by  the  disease  which  has  affected  the  patient  primarily; 


18  PARACENTESIS  OF   THE  PERICARDIUM. 

hence,  as  idiopathic  pericarditis  is  rare,  it  is  difficult  to 
present  the  incipient  syniptoms  to  the  reader  in  a  categor- 
ical manner.  There  is,  frequently,  a  slight  amount  of 
pain  or  uneasiness  experienced,  referred  to  the  precordial 
region,  or  shooting  in  various  directions  from  it;  there 
may  be  tenderness,  especially  when  pressure  is  made  upon 
the  epigastrium  upwards  in  the  direction  of  the  heart. 
This,  however,  does  not  furnish  very  valuable  evidence, 
for  acute  gastritis,  pleuritis,  and  hepatic  trouble  will  pre- 
sent a  similar  symptom.  It  has  been  suggested  that  the 
study  of  the  special  pain  due  to  pericarditis  has  been 
perhaps  too  much  neglected,  and  attempts  have  been 
made  to  study  the  characters  and  semeiological  value  of 
the  pain  connected  with  pericarditis  itself,  omitting  that 
dependent  upon  complications.*  Absence  of  pain  is  said 
by  some  to  be  more  frequent  in  complicated  than  in 
simple  pericarditis,  but  this  point  is  of  little  practical 
value. 

The  slight  exacerbation  of  fever  and  the  occurrence  of 
rigors  that  would  be  expected  as  an  accompaniment  of 
inflammation  of  this  serous  membrane  may  be  absent, 
or  veiled  by  the  febrile  action  belonging  to  the  primary 
rheumatic  or  nephritic  disorder.  There  may  be  disturb- 
ance of  the  cardiac  action,  as  shown  by  palpitation  and 
increased  frequency  of  action,  which  also  causes  rather 
hurried  respiratory  eftbrts.  When  the  sac  becomes  occu- 
pied by  a  quantity  of  fluid  sufficient  to  induce  symptoms, 
we  have  the  same  train  in  pericarditis  with  exudation,  and 
in  hydro-pericardium.  The  heart  and  the  adjacent  organs 
become  involved  by  reason  of  the  mechanical  results  of  the 
fluid  accumulation.  The  pulse  may  be  feeble,  frequent, 
and  even  irregular;    there  may  be  more  or  less  urgent 

*  Lo  Sperimentale,  tomo  xl.  (1877)  p.  419. 


SYMPTOMS   OF  PERICARDIAL  EFFUSION. 


19 


Fig.  1. 


dyspnoea  or  even  orthopnoea;  and  oppression  referred  to  the 
cardiac  region  may  be  present. 

Traube  has  stated  that  some- 
times in  copious  effusion  the  left 
carotid  and  radial  arteries  pulsate 
less  strongly  than  on  the  right 
side,  but  he  is  unable  to  explain 
it.  The  disturbed  circulation 
and  respiration  is  due  partly  to 
the  fact  that  the  fluid  prevents 
perfect  dilatation  of  the  auricles, 
and  hence  the  venous  return 
from  the  lungs  is  interfered  with. 
Moreover,  there  is  pressure  ex- 
erted upon  the  lungs  and  left 
bronchus.  (Fig.  1.)  Occasionally 
there  is  fulness  of  the  veins  of 
the  neck,  and  at  times  venous 
pulsation,  due,  probably,  to  the 
pressure  of  the  fluid  upon  the 
thin-walled  right  auricle  and  the 
intra-pericardial  portion  of  the 
descending  vena  cava.  A  dry  cough,  due  to  reflex  irrita- 
tion of  the  larynx,  and  vomiting  are  occasional  accom- 
paniments. Venous  congestion  of  the  right  side  of  the 
heart  and  the  lungs,  with  pallor  and  perhaps  cyanosis  of 
the  peripheral  parts  of  the  body,  would  be  expected. 
These  symptoms  are  due  to  the  interference  with  the  car- 
diac impulse,  as  well  as  to  the  pressure  of  the  enlarged  sac 
upon  the  veins  and  lungs,  which  have  no  opportunity  for 
full  expansion.  Singultus  at  times  occurs,  due  perhaps 
to  inflammation  of  the  phrenic  nerve ;  there  may  be  dys- 
phagia also  as  an  accompaniment.  During  this  time  ner- 
vous symptoms,  due  to  imperfect  cerebral  circulation,  are 


Case  of  chronic  pericarditis  in  which 
three  and  one-fourth  pounds  of  fluid 
were  contained  in  the  sac. — Reynolds. 


20  PARACENTESIS   OF   THE   PERICARDIUM. 

shown,  and  the  patient  may  have  frequent  attacks  of  syn- 
cope, during  which  he  may  succumb.  If  he  do  not  die 
from  sudden  syncope  on  exertion,  the  end  may  occur  from 
oedema  of  the  lungs;  or,  after  presenting  delirium,  he  may 
sink  into  a  comatose  condition.  The  effusion  is  sometimes 
complicated  with  myocarditis,  which  of  course  increases 
the  severity  of  the  circulatory  symptoms.  The  equivocal 
character  of  these  subjective  symptoms  serves  to  render 
prominent  the  value  of  the  physical  signs  of  pericardial 
effusion,  without  a  knowledge  of  which  operative  meas- 
ures would  seldom  have  been  undertaken.  By  these  we 
are  enabled  to  watch  the  course  of  the  affection  almost 
from  the  moment  of  hypersemia,  and  estimate  in  a  some- 
what accurate  manner  the  amount  and  quality  of  the  con- 
tained liquid. 

THE    PHYSICAL    SIGNS. 

Let  us,  then,  discuss  the  results  found  upon  physical 
exploration  in  cases  of  suspected  pericardial  effusion.  In 
the  first  place.  What  is  discovered  by  inspection  and  pal- 
pation ?  If  the  pericardium  is  greatly  distended  there  will 
be  some  evidence  of  increased  prominence  of  the  chest 
wall,  with  perhaps  elevation  of  the  nipple,  and  it  would 
be  natural  to  imagine  that  the  increase  of  the  left  side 
would  be  especially  marked  in  the  pr?ecordial  region.  It 
is  stated  that  the  ribs  are  elevated,  thus  presenting  an 
appearance  similar  to  what  is  seen  during  the  time  of  in- 
spiration. It  must  be  borne  in  mind  that  the  bulging  is 
seldom  sufficient  to  be  a  marked  feature  of  the  case,  since 
most  patients  will  recover  or  the  disease  prove  fatal  before 
sufficient  fluid  has  collected  to  give  rise  to  any  great  in- 
crease in  girth.*     There  have  been  instances,  I  believe, 

*  In  young  children  with  their  flexible  parietes  this  prominence  of  the 
cardiac  region  is  of  more  value  than  in  the  old,  where  rigidity,  deformity 


PHYSICAL  SIGNS.  21 

where  tlie  bulging  is  said  to  have  resembled  the  pointing 
of  an  abscess.  Should  there  be  old  adhesions  of  the 
pleura,  or  very  rigid  chest  walls,  this  sign,  as  mentioned 
above,  would  not  be  of  much  value.  Again,  other  affec- 
tions of  the  heart  itself,  such  as  hypertroph}-,  and  pulmo- 
nary affections,  or  mediastinal  growths  may  present  a 
similar  appearance.  Fulness  of  the  epigastrium  may 
occur  in  pericardial  dropsy  from  depression  of  the  dia- 
phragm, and  there  may  also  be  evident  some  congestive 
swellins;  of  the  liver.  It  has  been  thouo:ht  that  a  visible 
undulation,  imagined  to  be  due  to  the  heart's  contraction 
and  dilatation  setting  the  serum  in  vibration,  is  an  evi- 
dence of  effusion ;  but  this  has  been  denied,  and  the  un- 
dulatory  movement  has,  on  the  contrary,  been  attributed 
to  the  actual  cardiac  impulse,  rendered  visible  by  trans- 
mission to  the  surface,  when  there  is  no  large  amount  of 
effusion  present. 

Palpation  in  pericarditis  furnishes  little  information  ex- 
cept as  to  the  locality  of  the  apex  beat,  which  can  perhaps 
be  determined  better  by  auscultation,  provided  there  is  not 
sufficient  fluid  to  mask  all  sounds  entirely,  in  which  case 
both  palpation  and  inspection  are  unavailable.  The  char- 
acter of  the  apex  beat  may  be  determined,  but  it  is  the 
change  of  position  to  which  most  importance  is  to  be 
attached.  When  the  sac  is  distended  the  heart  can  move 
more  readily,  and  hence,  if  the  patient  lie  upon  the  left 
side,  the  beat  is  felt  rather  more  to  the  left  than  before 
the  alteration  of  decubitus.  It  should  be  remembered, 
however,  that  a  certain  amount  of  mobility  of  this  nature 
occurs  normally.  Again,  in  inflammation  the  effusion  is 
apt  to  begin  about  the  root  of  the  organ,  and  consequently 

from  injury,  emphysema,  intra-thoracic  tumor,  and  other  atfections  of 
advancing  life,  serve  to  alter  the  physical  conformation  of  the  chest. 


22  PARACENTESIS  OF  THE  PERICARDIUM. 

may  push  the  heart's  base  downward,  and  thus,  making 
it  take  a  more  horizontal  position,  thrust  the  apex  beat  to- 
wards the  left,  whatever  be  the  patient's  position.  When 
there  is  sufBcient  fluid  to  push  the  heart  backward  and 
prevent  contact  with  the  thoracic  parietes,  the  impulse 
will  become  imperceptible.  This  will  vary  as  to  the  time 
of  its  occurrence  with  the  strength  of  the  heart  as  well  as 
with  the  amount  of  fluid;  evidently,  more  intervening 
fluid  will  be  requisite  to  deaden  a  strong  cardiac  impulse 
than  a  weak  one.  Provided  the  power  of  the  patient's  apex 
beat  be  known  to  the  observer,  it  is  possible  to  gain  a  par- 
tial idea  of  the  variations  occurring  in  the  amount  of  fluid 
contained  in  the  pericardium.  In  cases  that,  from  pre- 
ceding inflammation,  have  the  parietal  and  visceral  layers 
of  pericardium  adherent  in  places,  there  will  be  little  or 
no  change  in  the  locality  or  power  of  the  apex  beat. 
Sometimes  the  impulse  can  be  more  certainly  felt  and 
appreciated  by  allowing  the  subject  to  sit  up  or  lean  for- 
ward, since  this  permits  the  organ  to  fall  forward  towards 
the  sternum,  and  impinge  once  more  against  the  costal 
cartilages  and  ribs.  Finally,  palpation  at  times  furnishes 
evidence  of  pericarditis,  by  reason  of  a  friction  fremitus 
being  perceptible  to  the  surgeon  as  he  lays  his  hand  over 
the  prtecordium. 

Of  all  the  methods  of  exploration  the  most  useful  in  the 
physical  examination  of  suspected  pericardial  effusion  is 
certainly  percussion ;  for,  by  the  deviation  from  the  nor- 
mal area  of  dulness,  and  by  the  variations  occurring  from 
day  to  day,  a  quite  definite  idea  of  the  pathological  changes 
can  be  obtained.  It  is  impossible  to  state  how  small  a 
quantity  of  serum  will  make  its  presence  distinguishable 
by  increasing  the  cardiac  dulness.  Bauer  says  we  must 
not  expect  notable  changes  if  the  quantity  be  less  than 
one   hundred   cubic   centimetres,  though  there   may  be 


PHYSICAL   SIGNS.  23 

many  circumstances  to  invalidate  any  conclusions  based 
upon  this  statement.  The  same  writer  is  of  the  opinion 
that  stress  is  to  he  laid  upon  the  fact  that  the  effusion  in- 
creases the  area  of  relative  cardiac  dulness ;  meaning  by 
relative  dulness  the  impaired  resonance  found  at  the  pe- 
riphery of  the  region  of  absolute  dulness,  where  the  lung 
overlies  the  front  of  the  heart.  It  is  said  that  there  may 
be  considerable  serosity  in  the  sac  without  any  change  in 
the  area  of  absolute  cardiac  dulness,  and  consequently  the 
change  in  the  region  of  impaired  resonance  is  worthy  of 
being  noted.  This  statement  I  believe  to  be  correct,  for 
I  have  seen  in  the  dead-room  the  edge  of  the  lung  overlie 
the  pericardium  to  such  an  extent  that  there  was  little  or 
none  of  its  surface  exposed.  Consequently  an  eftusion  of 
considerable  amount  could  be  present  in  such  a  case  and 
hardly  afford  any  region  whatever  of  absolute  dulness  ; 
and  if  it  was  found  in  a  case  of  suspected  effusion  that 
there  was  a  small  area  of  absolute  dulness,  it  would  un- 
doubtedly be  attributed  to  the  ordinary  exposed  portion 
of  the  heart.  Hence  it  is  of  major  importance  to  define 
the  region  of  relative  or  partial  dulness,  rather  than  to  pay 
attention  exclusively  to  the  extent  of  absolute  impairment 
of  resonance.  Rotch  says  that  by  percussion  of  the  fifth 
right  intercostal  space  he  was  able  to  diagnosticate  the 
existence  of  seventy  to  eighty  cubic  centimetres  of  fluid 
introduced  into  the  sac  experimentally.* 

The  various  factors  which  produce  greater  intensity,  as 
well  as  greater  extent  of  the  relative  dulness,  must  accord- 
ingly be  discussed.  In  the  first  place,  then,  the  distended 
pericardium  compresses  the  lung  in  front  of  it  against  the 
chest  wall,  and  causes  impaired  resonance  by  preventing 
perfect  expansion  during  inspiration,  and  by  furnishing 

*  Boston  Med.  and  Surg.  Journ.,  Oct.  3,  1878,  p.  423. 


24 


PARACENTESIS   OF  THE   PERICARDIUM. 


a  non-resonant  collection  of  fluid  behind  the  thin  layer 
of  pulmonary  tissue.  If  the  lung  he  non-adherent  to  the 
adjacent  tissues,  it  may  be  forced  laterally  and  backwards, 
and  so  increase  the  surface  over  which  there  is  found  a 
percussion  note  of  absolute  dulness.  On  the  other  hand, 
if  there  be  old  pleuritic  bands,  or  if  there  exist  intra- 
pericardial  adhesions,  the  area  of  dulness  will  be  exceed- 
ingly irregular  in  outline.  The  comparative  elasticity  of 
the  pulmonary  tissue  has  also  some  agency  in  the  produc- 
tion of  a  large  area  of  relative  dulness,  since,  if  the  lung 
be  more  or  less  non-compressible,  it  will  require  greater 
intra-pericardial  tension  to  effect  its  compression  against 
the  anterior  wall  of  the  chest.  Thus  much  for  the  me- 
chanical occurrence  of  increased  dulness  in  effusions 
within  the  pericardium. 

The  diagnosis  of  the  condition  is  rendered  much  easier, 

as  may  readily  be  seen,  when 
the  increase  in  dulness  is  sud- 
denly developed  under  the  ob- 
servation of  the  physician,  as 
this  would  preclude  the  possi- 
bility of  the  variation  in  per- 
cussion being  due  to  cardiac 
hypertrophy,  chronic  indura- 
tion of  the  lung,  or  any  analo- 
gous pathological  change.  It 
has  long  been  asserted  that  the 
shape  of  the  region  of  cai-diac 
dulness  in  cases  of  effusion  is 
that  of  a  rude,  truncated  tri- 
angle, with  the  apex  at  the 
root  of  the  great  vessels,  and 
the  base  downwards.  (Fig.  2.) 
Whether  this  is  true  may  be  discussed  subsequently.     One 


Fig.  2. 


Rheumatic  pericarditis,  showing  re- 
gion of  dulness  on  percussion  at  period 
of  the  acme. — Reynolds. 


PHYSICAL  SIGNS.  25 

of  the  surest  sis-ns  of  fluid  in  the  sac  is  the  existence  of 
relative  dulness  to  the  left  of  the  apex,  due  to  the  serum 
pressing  the  loose  fibro-serous  membrane  away  from  the 
heart.  Hayden  thinks  this  test  not  available,  because  we 
cannot  tell  where  the  apex  is  normally  located.*  An  im- 
portant point  would  be  dulness  below  the  apex  beat,  if  that 
fact  were  determinable,  as  it  sometimes  is.  The  fluid,  if 
considerable,  would  tend  to  depress  the  diaphragmatic  por- 
tion of  the  pericardium  away  from  the  heart,  which,  though 
heavy,  is  suspended  in  the  pericardial  cavity  by  means  of 
the  vessels  at  its  base,  hence  the  apex  beat  is  found  above 
the  lowest  limit  of  dulness.  It  is  usually  taught  in  the 
class-room  that  the  area  of  dulness  in  pericardial  eff'usion 
is  triangular,  and  this  is  given  as  a  valuable  diagnostic 
point.  If  we  could  always  have  an  otherwise  normal  peri- 
cardium equably  distended,  without  any  intra-pericardial 
attachments,  and  a  pulmonary  tissue  with  no  pleural  ad- 
hesions, and  with  the  normal  conformation  of  outline,  we 
might  occasionally  see  a  typical  pyramidal,  or  triangular 
area  of  dulness  when  the  patient  was  upright.  That  these 
conditions  are  almost  unattainable  in  cases  of  chronic  dis- 
ease, such  as  gives  rise  to  large  eff'usions,  makes  it  evi- 
dent that  he,  who  expects  to  find  the  beautifully  triangular 
outline  described  in  books  and  lectures,  vdll  be  doomed  to 
disappointment. 

After  I  had  written  the  above  paragraph,  and  in  fact 
the  greater  portion  of  this  little  work,  and  had  stated  else- 
where my  doubt  as  to  the  p3'ramidal  area  of  dulness  to  be 
found  in  pericardial  effusion,  I  fortunately  saw  the  article 
of  Dr.  Rotch,  of  Boston,t  containing  his  elaborate  inves- 
tigations of  this   very  subject.     My  opinion,  which  was 


*  Diseases  of  Heart  and  Aorta,  American  Ed.,  1.  p.  388. 
f  Boston  Med.  and  Surg.  Journ.,  1878,  vol.  xcix.  pp.  389  and  421. 

8 


26  PARACENTESIS  OF   THE  PERICARDIUM. 

founded  on  theoretical  considerations,  that  the  fluid  would 
collect  at  the  bottom  of  the  sac  and  not  at  the  top,  as 
stated  by  many  writers,  is  the  same  as  that  held  by  him 
after  careful  experiments.  The  results  obtained  by  this 
gentleman  are  so  interesting  that  I  shall  give  a  summary 
of  his  method  of  experimentation,  and  an  abstract  of  the 
practical  points  obtained.  He  injected  the  pericardial  sacs 
of  a  number  of  subjects  with  melted  cocoa-butter,  and 
marked  out  with  ink  the  area  of  flatness  (absolute  dulness). 
Great  care  was  exercised  to  have  the  subject  semi-recum- 
bent, and  to  see  that  the  lungs  were  properly  inflated. 
Subsequently  the  sternum  was  removed,  and  the  condition 
of  the  intra-thoracic  organs  carefully  noted. 

"When  he  injected  a  small  amount  of  fluid  into  the  sac 
"  percussion  gave  an  increase  of  precordial  flatness,  as  fol- 
lows :  beginning  at  the  sixth  rib,  about  two  centimetres  to 
the  right  of  the  sternum,  it  passed  upwards  in  a  curved  line 
with  the  convexity  outwards  to  the  fourth  right  costal  car- 
tilage at  its  lower  edge,  then  across  the  sternum  to  the 
upper  border  of  the  fourth  left  costal  cartilage,  and  out- 
wards and  downwards  to,  and  to  the  outside  of,  the  nipple, 
passing  down  to  the  sixth  or  seventh  rib."  There  was,  he 
says,  no  vertical  increase  of  flatness,  which  corresponds 
with  Sibson's  statements.  It  must  be  recollected  that  he 
uses  the  term  flatness  to  signify  absolute  dulness.  When 
a  large  amount  of  fluid  was  introduced,  the  area  of  abso- 
lute dulness  was  found  to  be  as  represented  in  the  diagram, 
drawn  directly  from  the  cadaver  (Fig.  3). 

The  size  of  the  dull  area  varies  with  the  amount  of 
eftusion  and  the  compressibility  of  the  adjacent  tissues, 
and  also  depends  to  some  extent  upon  the  position  of  the 
patient.  In  the  supine  position  the  area  will  probably  be 
smaller  than  when  the  patient  is  sitting  upright  or  lean- 
ing forward,  so  there  may  be  considerable  deviation  in  the 


PHYSICAL  SIGNS.  27 

position  of  the  region  of  impaired  resonance  as  tlie  invalid 
lies  upon  one  or  other  side  of  the  body.  The  left  border 
is  apt  to  be  obliquely  to  the  left  and  downwards ;  the  right 
side  of  the  triangle  is  said  to  be  more  vertical  than  the  left, 
and  follows  the  border  of  the  right  lung  near  the  right  edge 

Fig.  3. 


Large  amount  of  liquid  introduced  into  sac. — Kotcli. 

B,  Liver.    B',  Portion  of  liver  covered  by  right  lung.    D,  Area  of  percussion  flat- 
ness caused  by  large  effusion.     S,  Sternum.     broken  line, — Border  of  lung. 

of  the  sternum.  The  base  of  the  dull  area  is  in  the  neigh- 
borhood of  the  sixth  or  seventh  rib.  In  cases  of  very  large 
chronic  effusions,  a  great  portion  of  the  front  of  the  thorax 
may  be  dull  on  percussion.  In  Pepper's  patient,  the  dull 
area  extended  from  a  point  one  inch  to  the  right  of  the 
sternum  to  two  inches  to  the  left  of  the  line  of  the  left 
nipple ;  the  upper  limit  v.'as  at  the  second  interspace,  and 
the  base  at  the  level  of  the  seventh  rib. 

Percussion   in  cases  of  large  pericardial  effusion  will 


28  PARACENTESIS   OF  THE    PERICARDIUM. 

generally  show  impaired  resonance  over  the  upper  part  of 
the  left  lung ;  the  note  is  higher  in  pitch  and  more  tympa- 
nitic than  on  the  right  side,  as  in  pleural  eftusions,  which 
impart  a  semi-tympanitic  note  to  the  subclavicular  re- 
gion. 

What  will  auscultation  reveal  in  cases  of  pericardial 
effusion  ?  The  friction  sound,  due  to  the  rubbing  to- 
gether of  the  inflamed  surfaces  of  the  visceral  and  parietal 
layers,  is  pathognomonic  of  pericarditis,  but  may  have 
disappeared  before  the  patient  comes  under  observation, 
on  account  of  rapid  eifusion  and  separation  of  the  surfaces ; 
or  may  not  appear  at  all  in  cases  where  the  effusion  pos- 
sesses more  the  character  of  a  simple  dropsical  transudation, 
and  where  very  little  inflammatory  lymph  is  furnished. 
The  presence  of  a  distinct  friction  sound  must  not  lead  us 
to  believe  that  there  is  but  little  fluid  in  the  sac,  for  it  has 
been  heard  where  two  pints  of  fluid  occupied  the  pericar- 
dial cavity.  It  is  usually,  but  not  always,  heard  best  near 
the  origin  of  the  great  vessels,  and  at  times  becomes  more 
audible  if  the  body  is  bent  forwards.  The  valvular  sounds 
of  the  heart  will  as  a  rule  become  more  feeble  or  entirely 
absent  during  the  occurrence  of  great  effusion,  being  in- 
fluenced very  much  as  the  apex  beat  is  modified  by  the 
same  pathological  condition.  The  second  sound,  however, 
is  usually  still  heard  over  the  base  of  the  heart  and  at  the 
top  of  the  sternum.  If  there  be  intra-pericardial  adhe- 
sions, the  heart-sounds  may  remain  quite  audible  at  certain 
positions,  though  the  effusion  be  large. 

We  have  thus  seen  that  the  physical  signs  of  effusion 
into  the  pericardium  are  much  more  reliable  and  definite 
than  any  of  the  symptoms  mentioned,  and  that  the  diag- 
nosis must  be  based  upon  the  former,  since  the  latter  are 
not  trustworthy  guides  to  the  pathological  condition. 


DIAGNOSIS.  29 

THE    DIAGNOSIS. 

After  a  consideration  of  the  physical  signs  of  pericar- 
dial eflusiou,  it  is  necessary  to  show  how  the  attendant 
may  make  the  diagnosis  between  this  condition  and  the 
several  diseases  that,  upon  exploration,  furnish  somewhat 
similar  results.  Ordinary  cases  of  pleurisy  are  easily  dis- 
criminated by  the  position  of  the  area  of  dulness  and  the 
normal  condition  and  position  of  the  heart-sounds  and 
apex  beat;  but  sacculated  pleuritic  effusions  in  the  ante- 
rior thoracic  region  niay  give  rise  to  much  difficulty.  Ac- 
curate percussion  and  careful  auscultation  would  probably 
prove  that  the  heart  was  displaced  to  the  right  in  saccu- 
lated pleural  effusion  of  the  left  side.  A  pleural  effusion 
in  the  region  anterior  to  the  heart  pressing  this  organ 
bactward  is  conceivable,  and  as  the  triangular  pericardial 
dulness  is  not  reliable,  such  a  case  would  be  very  per- 
plexing. Retraction  of  the  lung,  exposing  more  than 
usual  of  the  heart's  surface  or  pneumonic  consolidation 
of  the  edge  overlying  the  heart,  could  only  be  diagnos- 
ticated by  auscultatory  signs,  such  as  normal  loudness 
of  heart-sounds  and  absence  of  friction  in  one  case,  and 
bronchial  respiration  in  the  other.  Mediastinal  abscesses 
and  growths  occurring  within  the  thorax  would  be  shown 
by  irregularity  of  dulness  and  displacement  of  the  cardiac 
sounds.  In  such  conditions  the  signs  would  be  so  variable 
that  it  is  impossible  to  lay  down  any  definite  diagnostic 
rules.  The  exploring-needle  or  trocar  might  give  infor- 
mation, and  in  my  opinion  would  be  perfectly  justifiable 
in  cases  where  an  accurate  diagnosis  was  demanded  by 
the  urgency  of  the  phenomena. 

That  care  in  physical  examination  and  a  correct  appre- 
ciation of  the  signs  presented  by  the  various  forms  of 
intra-thoracic  disease  is  requisite,  becomes  evident  when 


30  PARACENTESIS  OF   THE  PERICARDIUM. 

we  recollect  that  Desault  found  at  an  autopsy  that  he  had 
performed  thoracentesis,  while  the  pericardium,  which  he 
thought  he  had  tapped,  was  adherent.  Again,  in  B6hier's 
case,  a  question  has  been  raised  whether  he  did  not  with- 
draw the  fluid  from  the  pleura  instead  of  the  pericardium. 
That  a  left-sided  pleuritis  might  put  an  operator  at  fault  is 
readily  conceivable. 

At  a  meeting  of  the  l^ew  York  Pathological  Society,* 
some  specimens  of  pericarditis  and  pleurisy  of  the  left 
side,  taken  from  a  patient  whose  chest  had  been  aspi- 
rated twice,  were  shown  by  Dr.  Loomis ;  and  yet  it  was 
impossible,  even  after  the  autopsy,  to  say  whether  the 
needle  had  really  entered  the  pericardium  or  not.  The 
case  operated  upon  by  Labric  and  quoted  in  the  table  (jN'o. 
34)  is  even  more  remarkable.  The  child  was  supposed  to 
have  double  pleurisy  and  pericarditis.  He  wished  to  do 
thoracentesis,  and  punctured  the  wall  in  the  fifth  inter- 
space about  four  centimetres  outside  of  the  left  nipple. 
More  than  a  litre  of  purulent  serum  escaped.  The  patient 
subsequently  died,  and  the  autopsy  revealed  the  fact  that 
the  fluid  had  come  from  the  pericardium  and  not  from  the 
pleura,  which  was  adherent  to  the  lung.  This  case  of  un- 
intentional pericardial  tapping  shows  the  extent  to  which 
the  sac  may  be  distended. 

Hypertrophy  of  the  heart  is  usually  distinguishable  by 
the  heavy  first  sound,  the  character  of  the  pulse,  and  the 
general  symptoms.  If  a  pericardial  eff'usion  increases  slowly 
and  there  is  not  much  diminution  in  the  intensity  of  the 
sounds,  there  will  be  a  slight  resemblance  to  the  former 
condition.  The  differential  diagnosis  among  cardiac  dis- 
eases, which  it  is  most  necessary  to  study  thoroughly,  is 
between  efl:usion  and  dilatation,  since  in  each  there  occurs 

*  New  York  Medical  Journal,  1877,  vol.  ii.  p.  634. 


DIAGNOSIS.  31 

extension  of  the  area  of  diilness,  feebleness  of  the  sounds 
of  the  heart,  dyspnoea,  venous  congestion,  and  syncope. 
To  show  how  difficult  the  diagnosis  may  at  times  be,  I 
give  the  points  which  are  usually  mentioned  as  serving  to 
establish  the  diagnosis;  yet  an  attentive  study  of  them 
makes  it  evident  that  there  is  no  very  pathognomonic  sign 
to  which  surgeons  can  fix  their  faith.  In  eifusion  the  per- 
cussion dulness  is  stated  to  be  triangular  instead  of  square 
as  in  dilatation  ;  this  is  certainly  in  many  instances  not  the 
fact.  Again,  in  effusions  a  friction  sound  is  often  heard 
at  the  base  during  the  period  of  distended  pericardium ; 
but  in  hydro-pericardium,  or  non-inflammatory  dropsy, 
this  must  not  be  expected  any  more  than  in  dilated  heart. 
There  may  be  dropsy  and  venous  stagnation,  dyspnoea,  and 
cough  in  both  affections,  tliough  perhaps  more  frequently 
and  more  markedly  in  dilated  heart.  And  again,  the  his- 
tory is  of  little  avail  if  both  diseases  have  had  a  slow  onset. 
The  character  of  the  cardiac  sounds  is  perhaps  the  sign 
which  often  est  answers  a  true  purpose.  In  dilated  right 
heart  the  sounds  are  usually  clear  and  sharp,  though  feeble ; 
in  pericardial  effusion  they  are  feeble  and  distant  when 
one  auscults  at  the  apex,  but  more  distinct  when  one  listens 
at  the  upper  part  of  the  sternum.  A  sign  when  the  right 
auricle  is  dilated  is  pulsation  of  the  veins  of  the  neck, 
though  this  may  sometimes  ocovir  also  in  effusion.  A 
careful  weighing  of  the  points  will  usually  enable  the  at- 
tendant to  establish  the  diagnosis ;  but  it  is  to  be  recol- 
lected that  a  dilated  right  ventricle  has  been  punctured 
by  the  trocar  during  attempts  to  draw  off  a  supposed  peri- 
cardial effusion.  Fortunately,  these  cases  seem  to  show 
that  no  harm  results  from  this  undesirable  mistake.  Cases 
of  this  kind  have  come  under  my  notice  in  medical  litera- 
ture ;  therefore  let  one  weigh  every  symptom  and  sign 
in  doubtful  cases  before  proceeding  to  operate. 


32  PARACENTESIS   OF   THE  PERICARDIUM. 

The  diagnostic  sign  pointed  out  by  Rotch  is,  if  experi- 
ence proves  its  accuracy,  a  valuable  aid  to  the  surgeon 
about  to  perform  paracentesis  of  the  pericardium.  He 
says  flatness  at  from  two  to  three  centimetres  from  the 
right  edge  of  the  sternum,  in  the  fifth  intercostal  space, 
would  be  almost  absolutely  sufificient  to  mark  the  presence 
of  a  small  or  large  effusion,  unless  the  opinions  of  author- 
ities on  enlarged  heart  are  proved  to  be  incorrect.*  The 
diagram  on  page  27,  showing  the  area  of  flatness  in  effu- 
sion, must  be  compared  with  that  of  enlarged  heart  (Fig.  4) 

Fio.  4. 


Enlarged  heart. — Kotch. 

A,  Area  of  percussion  flatness  caused  by  enlarged  heart.  B,  Liver.  B',  Portion 
of  liver  covered  by  right  lung.  S,  Sternum.  EE'E",  Line  of  relative  dulness  of 
enlarged  heart. -  broken  Hue, — Border  of  lung. 

to  appreciate  fully  this  assertion.  The  latter  represents  the 
area  of  flatness  due  to  a  heart  increased  in  size  by  hyper- 
trophy or  dilatation,  as  described  by  standard  authorities, 

*  Boston  Med.  and  Surg.  Journ.,  1878,  vol.  xcix.  p.  427. 


DIAGNOSIS.  33 

and  it  is  seen  that  there  is  little  or  no  absolutely  dull  area 
in  the  fifth  right  space.  He  suggests  also  that  puncture 
can  safely  be  performed  in  the  fifth  right  space  at  from 
four  and  one-half  to  five  centimetres  from  the  edge  of  the 
sternum. 

The  relation  of  some  of  the  instances  where  competent 
observers  were  foiled  may  be  mentioned  in  this  connection. 
Trousseau  came  very  near  tapping  a  case  where  subse- 
quent post-mortem  examination  showed  cardiac  hyper- 
trophy with  a  very  small  amount  of  effusion.  Roux's  case 
showed  great  dilatation  of  the  heart,  but  no  effusion  what- 
ever. Roo-er  mentions  the  case  of  a  child  suffering  with 
dilatation  and  valvular  disease  in  which  he  had  almost 
decided  to  do  paracentesis,  but  waited.  The  child  died, 
and  he  tapped  the  chest  after  death,  but  then  discovered 
that  there  was  no  trace  of  pericarditis.*  Hay  den  also  re- 
latesf  a  case  where  he  was  deceived  by  the  physical  signs 
in  a  somewhat  similar  manner.  The  most  remarkable 
instance  of  an  error  of  this  character  is  that  of  a  womanj 
who  had  pleuro-pneumonia  and  signs  of  large  pericardial 
efiusion ;  as  she  was  almost  moribund,  a  trocar  was  intro- 
duced at  the  fourth  interspace,  but  to  the  dismay  of  the 
operator  dark,  venous  blood  escaped.  The  instrument 
was  immediately  withdrawn,  and  the  patient  seemed  re- 
lieved of  the  distress  and  dyspnoea.  Four  weeks  later  she 
died  of  a  complication  of  disorders,  and  there  was  dis- 
covered dilatation  and  valvular  disease,  but  no  effusion. 
The  right  ventricle  had  been  tapped,  and  a  drachm  of 
blood  withdrawn  without  any  shock  to  the  patient.  On 
the  contrary,  the  abstraction  of  blood  seemed  to  relieve 
the  distended  and  engorged  heart  better  than  phlebotomy, 

*  Bull,  del  Acad,  de  Med.,  p.  1213. 

f  Diseases  of  Heart  and  Aorta,  American  ed.,  i.  p.  423. 
J  Transactions  Clinical  Society  of  London,  viii.  p.  169. 


34  PARACENTESIS  OF  THE   PERICARDIUM. 

as  was  evinced  by  the  diminution  of  threatening  symptoms 
and  the  decreased  area  of  duhiess. 

Though  these  histories  tend  to  discourage  us  in  under- 
taking the  operation,  still  the  results  of  paracentesis  in 
suitable  cases  are  so  brilliant,  that  we  must  be  prepared 
to  proceed  if  the  diagnosis  can  be  made  clear.  Many 
patients  succumb  because  tapping  has  not  been  performed. 
Dr.  Wilks  is  quoted*  as  saying  that  in  three  cases  of  puru- 
lent pericarditis,  seen  by  him  post-mortem,  where  tapping 
would  have  been  feasible,  the  diagnosis  had  not  been 
made.  Let  us,  then,  endeavor  to  clear  up  doubtful  points, 
and  make  an  effort  to  unravel  these  knotty  diagnostic 
questions. 

At  times  it  may  become  desirable  to  determine  whether 
the  effusion  is  the  result  of  inflammation  or  due  to  a  trans- 
udation. The  latter  has  the  following  characteristics :  it 
is  usually  a  part  of  a  chronic  general  dropsy,  and  is  apt 
to  be  an  event  subsequent  to  hydrothorax;  there  are 
no  severe  symptoms,  such  as  pyrexia,  at  the  beginning ; 
there  is  no  friction  sound,  and  very  little  disturbance  of 
the  heart's  action ;  as  a  rule  there  is  less  tendency  to  a 
large  amount  of  fluid  accumulation,  and  the  area  of  dul- 
ness  is  more  apt  to  vary  in  size,  and  to  be  altered  by 
changes  of  posture. 

I  have  not  mentioned  under  the  head  of  diagnosis  such 
affections  as  cerebral  inflammation,  gastric  irritability, 
etc.,  which  may  be  confounded  with  early  pericarditis, 
because  I  am  discussing  the  subject  in  its  surgical  aspect 
alone,  and  hence  have  only  to  do  with  the  exudation  stage. 

THE    PROGNOSIS. 

The  result  in  cases,  which  show  evidences  of  pericardial 
effusion,  nmst  vary  with  the  underlying  cause  of  the  con- 

*  Lancet,  1872,  i.  p.  893. 


PROGNOSIS.  35 

dition,  the  quantity,  and  also  the  quality  of  the  fluid  con- 
tained in  the  sac.  Inflammatory  effusions,  such  as  occur 
in  rheumatism,  if  of  small  amount,  are  to  he  regarded  as 
favorable  in  respect  to  absorption.  When  the  sac  contains 
many  ounces  of  sero-fibrinous  exudation,  the  probability  is 
that  the  absorbents  will  be  unable  to  deal  with  it,  and  that 
the  sac  will  become  more  and  more  distended,  and  the 
fluid  in  time  purulent.  In  this  event  the  cardiac  muscle 
is  liable  to  become  degenerated  from  the  occurrence  of 
myocarditis,  which,  moreover,  is  at  times  a  complication 
of  serious  import  from  the  early  days  of  the  disease. 

When  pus  forms  absorption  is  wellnigh  impossible,  and 
the  patient  is  likely  to  die  from  exhaustion  or  the  results 
produced  by  the  purulent  collection,  unless  surgical  relief 
is  given  by  tapping.  Occasionally,  but  very  rarely,  there 
may  be  a  spontaneous  evacuation  of  the  j^us  through 
the  chest  wall,  producing  a  fistule.  In  non-inflammatory 
transudation  into  the  pericardium  the  prognosis  is  bad, 
because  it  results  from  some  such  condition  as  chronic 
nephritis,  and  is  but  a  symptom  of  serious  disease  else- 
where. The  immediate  danger  to  life  in  such  cases,  how- 
ever, may  exist  in  the  pericardial  effusion  rather  than  in 
the  primary  disease.  Moreover,  it  must  be  borne  in  mind" 
that  renal  symptoms,  even  the  presence  of  casts  in  the 
urine,  may  be  secondary  to  circulatory  disturbance,  result- 
ing from  the  fluid  in  the  pericardium.  Pepper's  case 
(No.  57)  is  an  illustration  of  this  important  fact. 

The  hemorrhagic  form  of  eff\ision  is  unfavorable,  on  ac- 
count of  its  being  due  to  important  blood  changes  which 
are  inconsistent  with  rapid  restoration  of  health;  still,  I 
should  be  inclined  to  consider  such  cases  more  amenable 
to  medical  treatment  alone  than  those  in  which  pus  fills 
the  sac.  In  the  latter  event  tapping,  if  the  condition  can 
be  recognized,  should  be  resorted  to  at  a  comparatively 


36  PARACENTESIS   OF   THE   PERICARDIUM. 

early  period,  before  surrounding  structures  suffer  from 
the  pathologicul  processes  going  on  within  the  pericardial 
membrane. 


CHAPTER    III. 

TREATMENT. 

The  ordinary  cases  of  pericarditis  are  undoubtedly 
amenable  to  treatment  by  medical  means,  which  should 
consist  of  such  remedies  as  are  used  in  the  management 
of  pleuritis.  In  rheumatic  pericarditis  of  moderate  se- 
verity nothing  is  required  but  a  continuance  of  the  anti- 
rheumatic medication.  Should  the  inflammation  of  the 
pericardium  assume  greater  severity,  it  would  be  necessary 
to  direct  our  energies  to  its  alleviation,  as  is  also  neces- 
sary in  cases  of  idiopathic  character.  When  there  is 
hydro-pericardium  dependent  upon  nephritis,  or  other 
causal  conditions  producing  dropsy,  the  attendant  is  of 
course  to  look  to  the  primary  affection,  and  at  the  same 
time  get  rid  of  the  fluid  in  the  sac  by  making  use  of  ab- 
sorbents. The  activity  of  treatment  depends  upon  the 
fact  that  the  anatomico-physiological  relation  of  parts  en- 
hances the  importance  of  a  very  few  fluidounces  of  serum 
in  this  locality. 

When  acute  sthenic  pericarditis  is  diagnosticated,  it  may 
at  times  be  advantageous  to  apply  leeches  or  cups  to  the 
prsecordium,  but  I  have  little  idea  that  general  blood- 
letting is  often  required.  Let  it  be  known,  however,  that 
I  should  not  hesitate  to  employ  it  if  the  case  seemed  a 
proper  one.  Those  who  follow  the  German  teaching  will 
most  probably  resort  to  cold  locally,  as  an  antiphlogistic 
and  anodyne  agent,  and  it  would  seem  to  be  a  rational 


TREA  TMENT.  37 

iiieasnre.  I  must  admit,  however,  that  my  preference  is 
for  warm  dressings,  such  as  poultices,  since  it  is  certainly 
a  fact  that  great  relief  is  aiForded  by  jacket-poultices,  or  in- 
deed anything  furnishing  heat  and  moisture,  in  pulmonary 
inflammations ;  therefore  they  seem  indicated  in  cardiac 
inflammations.  Stimulants  should  he  avoided,  and  small 
doses  of  cardiac  depressants  would  he  advantageous  in  this 
acute  form,  if  care  were  observed  to  watch  the  effect. 

In  order  to  keep  the  inflamed  organ  quiet  opium  is  of 
value,  if  the  patient  be  not  suffering  from  chronic  Bright's 
disease,  when  it  must  be  cautiously  employed.  Aperients, 
diaphoretics,  and  the  like  come  in  as  adjuvants,  as  in  all 
inflammations.  As  soon  as  there  is  evidence  of  cardiac 
failure,  whatever  be  the  stage  of  the  disease,  digitalis  is 
indicated,  and  may  be  combined  with  alcohol  in  some 
form.  As  salicylic  acid  seems  to  exert  a  favorable  influ- 
ence on  rheumatism,  it  may  have  a  tendency  to  prevent 
the  occurrence  of  pericarditis ;  so  also  the  alkalies  and 
bromide  of  ammonium  may  possibly  have  a  beneficial 
eflfect.  When  effusion  of  serum  or  exudation  of  Ij-mph 
has  occurred,  our  attention  is  directed  to  preventing  the 
increase,  and  promoting  the  absorption  of  these  products. 
Tincture  of  iodine,  blisters,  iodide  of  potassium,  diuretics, 
and  hydragogues  all  come  into  play.  At  the  same  time 
this  action  is  to  be  assisted  by  tonics,  stimulants,  nutritious 
diet,  and  digitalis ;  for  now  the  patient  has  begun  to  lose 
strength,  and  the  vigor  of  the  cardiac  muscle  is  impaired. 
Perhaps  also  myocarditis  may  have  rendered  the  heart 
more  feeble  than  the  pericardial  inflammation  would  in- 
duce of  itself.  My  own  instincts  would  lead  me  to  rely 
upon  poultices  and  anod^-nes,  iodide  of  potassium,  acetate 
of  potassium  and  juniper,  digitalis  and  tonics,  in  the 
various  stages  of  the  affection,  with  restriction  of  the 
amount  of  liquid  drank  during  the  time  of  effusion.     If 


38  PARACENTESIS   OF   THE  PERICARDIUM. 

liemorrhagic  pericarditis  was  suspected,  it  would  be  well 
to  use  the  preparations  of  ergot  in  addition  to  the  regimen 
and  medication  adapted  to  the  scorbutic  or  purpurous 
condition. 

I  have  said  nothing  regarding  mercury  as  an  antiplastic 
agent,  as  its  value  is  doubted  by  so  many  recognized 
authorities.  In  the  stage  of  exudation  it  could  perhaps 
be  advantageously  combined  with  the  iodide  of  potassium 
and  the  diuretic  chosen.  In  cases  of  sudden  asiDhyxia,  re- 
lief may  be  obtained  perhaps  by  venesection,  which  acts 
mechanically  by  reducing  the  amount  of  blood  to  be  oxy- 
genated and  renders  absorption  more  active. 

When  the  line  of  medical  therapeutics  indicated  has 
been  followed,  and  the  effusion  nevertheless  continues  to 
augment,  until  symptoms  of  gravest  import  arise,  and 
there  is  danger  of  fatal  consequences,  or  when  the  peri- 
cardial fluid  becomes  purulent,  which  at  all  times  means 
mischief,  we  must  throw^  aside  medicinal  agents  and  turn 
to  the  domain  of  surgery. 

Whenever  dropsy  of  peritoneum,  pleura,  ovary,  or  knee- 
joint  bafiles  our  medical  armamentarium,  we  have  recourse 
to  operative  measures,  and  decide  that  that  which  cannot 
be  absorbed  must  be  removed  by  tapping.  Is  it  possible 
to  apply  this  same  logic  to  pericardial  effusions  ?  and  if 
so,  what  are  the  results  of  such  an  operative  procedure  ? 
This  brings  us  to  the  consideration  of  paracentesis  as  a 
means  of  relief  in  pericardial  effusions. 

HISTORY    OF   THE    OPERATION. 

Paracentesis  was  proposed  by  Riolan*  as  far  back  as 
1649,  in  these  words, — "  Si  non  possis  exhaurire  istud  per 
hydragogen,  licetne   terebra   sternum   aperire  intervallo 

*  Enchiridion  Anatom.,  lib.  iii.  c.  4  (1649). 


HISTORY  OF   THE   OPERATION.  39 

pollicis  a  cartilagine  xiphoide  ?"  though  I  can  find  no  in- 
stance of  its  heing  performed  until  Romero,  of  Barcelona, 
operated  successfully,  and  reported  his  cases  to  the  Faculty 
of  Medicine  of  Paris.  Of  the  date  of  these  operations  I 
am  in  douht,  hut  they  are  mentioned  hy  Merat  in  his  work 
published  at  Paris  in  1819.*  The  operation  was  not  adopted 
because  of  the  difficulty  of  making  a  differential  diagnosis 
between  pericardial  effusions  and  other  affections,  and 
because  of  the  supposed  vulnerability  of  the  heart.  That 
the  first  reason  was  valid  is  shown  by  the  fact  that  some 
of  the  earlier  cases  of  so-called  tapping  of  the  pericardium 
were  not  instances  of  this  operation  at  all.  Desault  mis- 
tookf  a  circumscribed  pleuritic  effusion  for  pericardial 
dropsy,  and  actually  operated,  but  the  subsequent  autopsy 
revealed  the  fallacy.  Larrey  has  been  reported  as  perform- 
ing paracentesis  of  the  pericardium,  but  this  also  is  prob- 
ably not  the  fact.|  Thus  it  is  seen  that  the  obscurity 
involving  thoracic  diseases  before  the  application  of  phys- 
ical examination  to  the  unravelling  of  their  mysteries,  was 
doubtless  the  chief  cause  of  rejecting  the  operation.  Van 
Swieten  recognized  the  difficulty,  but  truly  says,  "  Ten- 
tandum  esse  potius  anceps  remedium  quam  nullum,  dum 
certa  pernicies  imminet," — A  doubtful  remedy  must  be 
tried  rather  than  none  at  all,  when  death  is  certainly 
threatening.  Hence  we  may  re*adily  perceive  that  the 
doubtful  remedy  would  have  been  tried  had  the  surgeon 
been  certain  that  the  presence  of  a  large  pericardial  effu- 
sion was  the  cause  of  the  threatening  symptoms.  There 
undoubtedly  lingered  also  a  feeling  that  the  heart  was  too 
vital  an  organ  to  allow  the  rude  approach  of  instruments, 
for  Merat  informs  us  that  the  Faculty  of  Medicine  at  Paris 

*  Dictionnaire  des  Sciences  Medicales,  xl.  p.  372. 

j-  CEuvres  Chirurg.  recueillies  par  Bichat,  ii.  1798  (Trousseau). 

X  Bulletin  des  Sciences  Medicales,  1810  (Trousseau). 


40  PARACENTESIS   OF  THE  PERICARDIUM. 

did  not  allow  the  report  of  Romero's  successful  cases  to 
be  printed  in  their  Transactions,  lest  this  most  delicate 
operation  should  thus  be  sanctioned. 

^Notwithstanding  the  discouraging  circumstances  sur-. 
rounding  the  operation,  writers  continued  to  advise  it  in 
suitable  instances,  and  operators  of  sufficient  courage  began 
to  appear  with  greater  frequency  as  the  profession  gained 
more  and  more  insight  into  the  physical  signs  of  the  con- 
dition. Karawagen  employed  the  trocar  in  treating  scor- 
butic pericarditis,  and  was  soon  followed  by  Kyber,  in 
similar  cases,  who  was  so  fortunate  as  to  have  four  recov- 
eries subsequent  to  the  operation.  The  importance  of  the 
subject  was  scarcely  appreciated  until  thoracentesis  became 
established  as  the  proper  method  of  dealing  with  large 
and  chronic  pleural  etlusions ;  but  even  then  there  was, 
and  up  to  the  present  time  there  remains,  a  feeling  of  dis- 
trust in  respect  to  the  operation.  In  an  article  published 
three  years  ago*  I  endeavored  to  place  the  aperation  on 
a  firmer  foundation,  and  trust  that  I  have  been  able  to  do 
something  in  that  direction. 

ANATOMY    OF   THE    PAKTS    CONCERNED. 

Before  entering  upon  the  consideration  of  the  operation 
itself,  it  will  be  profitable,  perhaps,  to  spend  a  little  time 
in  rehearsing  the  anatomical  relations  of  the  pericardium. 
The  pericardium  is  a  fibro-serous  sac  enclosing  the  heart 
and  the  roots  of  the  great  vessels,  or  rather,  surrounding 
and  being  reflected  upon  them  in  such  a  manner  that  the 
serous  layer  serves  as  a  covering  to  them  in  the  same 
manner  as  the  peritoneum  does  to  the  abdominal  organs. 
The  outer  portion  of  the  serous  layer  is  reinforced  by  a 
fibrous  layer.     The  space  between  the  visceral  layer  and 

*  Paracentesis  of  the  Pericardium,  N.  Y.  Medical  Journal,  Dec.  1876. 


ANATOMY  OF   THE   PARTS   CONCERNED.  41 

the  outer  fibro-serous  layer  is  the  cavity  of  the  pericardium, 
and  it  is  here  that  the  effusion  collects  in  cases  of  inflam- 
mation or  dropsy.  The  sac  is  conical,  with  the  apex  at- 
tached around  the  vessels  about  two  inches  above  their 
origin  and  directly  behind  the  top  of  the  sternum,  and 
with  its  base  connected  with  the  centre  of  the  diaphragm. 
The  pericardium  and  heart  lie  in  the  middle  mediastinum, 
between  the  two  pleural  sacs.  The  costal  pleura  is  reflected 
upon  the  outside  of  the  pericardial  sac  on  each  side  as  it 
passes  backward  from  the  sternum  to  go  to  the  root  of  the 
lung ;  from  the  lateral  region  of  the  pericardium  it  passes 
upon  the  lung  to  become  continuous  with  the  pulmonary 
layer,  Near  the  middle  of  the  sternum  the  two  pleurse  are 
sometimes  in  contact  for  a  short  distance,  but  they  diverge 
above  and  below,*  The  pleural  sacs  cover  the  pericardium 
in  front,  except  a  narrow  strip  running  vertically  along  the 
left  edge  of  the  sternum ;  hence,  unless  the  aspirating 
trocar  puncture  at  this  point,  the  pleura  must  be  injured 
before  the  pericardium  can  be  pierced,  when  the  parts  re- 
tain their  normal  relations. f 

The  heart,  covered  by  the  visceral  layer,  lies  within  the 
fibro-serous  layer,  behind  the  lower  two-thirds  of  the  ster- 
num, and  in  an  oblique  direction,  with  its  base  directed 
towards  the  right  shoulder.  It  e^^tends  about  three  inches 
to  the  left  of  the  median  line,  but  only  about  one  and  a 
half  inches  to  the  right  of  it.  The  upper  border  is  on  a 
level  with  the  superior  edge  of  the  third  costal  cartilage, 
while  its  inferior  surface  lies  upon  the  diaphragm  with  the 
pericardium  interposed.  The  apex  of  the  heart  is  located 
between  the  fifth  and  six  cartilages,  about  one  inch  inside 
and  two  inches  below  the  left  nipple.     The  lower  border 

*  Braune's  Topographical  Anatomy,  Plates  XII.  and  XIII.,  English 
edition,  1877.     See  also  p.  106. 

f  See  woodcuts  in  Braune,  on  pages  102-113,  and  Plates  XII.,  XIII. 

4 


42  PARACENTESIS   OF   THE  PERICARDIUM. 

of  the  heart,  in  a  frozen  section  made  by  Braune,*  corre- 
sponded with  the  lower  edge  of  the  fifth  rib,  wliile  the 
pericardium  extended  about  half  an  inch  lower,  and  con- 
tained about  a  tablespoonful  of  frozen  fluid. 

To  determine  the  extent  of  the  normal  pericardium,  I 
recently  made  an  examination  of  an  emaciated  female  sub- 
ject of  moderate  stature.  She  had  died  of  phthisis,  but 
there  was  no  pleural  eflJ'usion  to  interfere  with  the  normal 
relations.  I  sawed  through  the  sternum  between  the 
second  and  third  cartilages,  and  turned  it  carefully  down- 
wards, 80  as  not  to  displace  the  pleurae  or  pericardium. 
Having  cut  a  slit  in  the  pericardial  sac,  I  introduced  my 
finger,  and  obtained  its  dimensions  by  placing  the  finger 
at  the  right  and  left  limit  successively,  and  thrusting  a  long 
pin  through  the  overlying  tissues  until  it  touched  the  end 
of  the  finger.  The  measurements  were  then  taken  with 
accuracy.  There  was  about  half  a  fluidounce  of  fluid  in 
the  cavity.  The  sac  extended  to  the  right  of  the  median 
line  of  the  sternum  five  and  a  half  centimetres,  to  the  left 
of  the  middle  of  the  sternum  seven  centimetres.  The 
lower  border  of  the  pericardium  in  the  middle  line  cor- 
responded very  nearly  with  the  base  of  the  xiphoid  ap- 
pendix, but  at  its  apex  the  sac  descended  about  one  and 
one-half  centimetres  lower.  This  point  was  nearly  as  low 
as  the  inferior  border  of  the  sternal  end  of  the  sixth  rib, 
where  it  unites  with  the  sixth  cartilage.  Hence  a  line 
drawn  from  a  point  just  above  the  lower  edge  of  the  end 
of  the  sixth  rib  to  the  junction  of  the  xiphoid  and  glad- 
iolus would  correspond  with  the  oblique  floor  of  the  peri- 
cardium, and  give  its  lowest  boundary.  It  must  be  re- 
membered that  the  floor  of  the  pericardium  ascends  as  it 
passes  backward  upon  the  curved  upper  surface  of  the  dia- 

*  Op.  cit.,  p.  106. 


ANATOMY   OF   THE  PARTS  CONCERNED.  43 

phragm.  This  varies  during-respiration.  These  measure- 
ments are  probably  approximately  correct,  though  the  size 
of  the  individual  would  cause  differences.  When  the  sac 
is  distended  with  a  large  eifusion  the  diaphragm  is  pushed 
down,  and  the  limits  of  the  pericardium  increased  laterally. 
The  front  of  the  heart  and  pericardium  is  separated  from 
the  thoracic  wall  to  a  great  extent  by  the  lungs,  though 
these  organs  do  not  cover  as  much  of  the  pericardium  as 
the  pleurse,  which  extend  farther  forward.  The  right  lung 
comes  to  the  middle  of  the  sternum,  while  the  left,  at  the 
level  of  the  fourth  cartilage,  slopes  to  the  left,  leaving  the 
ventricles  uncovered  by  pulmonary  tissue.  This  gives  a 
notch  in  the  edge  of  the  left  lung,  exposing  the  right  ven- 
tricle and  the  apex  which  is  a  part  of  the  left  ventricle. 
This  uncovered  portion  is  rudely  triangular,  and  can  be 
indicated  by  a  circle  two  inches  in  diameter,  with  its  centre 
midway  between  the  nipple  and  the  end  of  the  sternum.* 
The  left  pleura  in  the  subject  mentioned  ran  straight 
down  quite  near  the  left  edge  of  the  sternum,  until,  about 
on  a  level  with  the  lower  end  of  the  gladiolus,  it  sloped 
off  to  the  left;  but  this,  as  is  seen,  did  not  correspond  with 
the  retraction  which  occurs  in  the  border  of  the  luno-  in 
the  vicinity  of  the  fourth  and  fifth  interspaces.  This  di- 
vergence of  the  pleura  from  the  sternum  occurred,  I  may 
say,  just  about  where  the  pericardium  and  diaphragm  came 
in  contact,  and  the  pleura  then  passed  upon  the  diaphragm. 
It  must  be  understood  that  the  measurements  spoken  of 
are  about  the  average,  and  that  pathological  conditions, 
and  possibly  anatondcal  variations,  may  cause  differences  in 
the  mutual  relations  of  the  organs.  It  is  easily  appreciated 
that  an  hypertrophied  heart  will  show  different  measure- 
ments, and  that  in  the  event  of  large  pericardial  effusion 

*  Holden's  Landmarks. 


44  PARACENTESIS   OF  THE   PERICARDIUM. 

or  of  pulmonary  disease  the  lung  may  not  intervene  be- 
tween the  heart  and  the  ribs.  The  pericardium  may  be 
greatly  distended  by  the  fluid,  and  depress  the  diaphragm 
to  a  considerable  extent,  and  then  correspond  in  level  with 
a  lower  rib  than  the  one  mentioned.  As  showing  what 
strange  anomalies  at  times  occur,  I  may  mention  that  a 
case  has  been  recorded*  where  the  pericardium  was  not 
attached  to  the  tendon  of  the  diaphragm  at  all,  but  was  a 
bag  simply  resting  on  that  muscle  without  any  continuity 
of  fibres  between  them. 

CASES    SUITABLE    FOR    GPERATIOISr. 

The  indications  for  tapping  the  pericardium  are  easily 
formulated.  Whenever  the  effusion,  whether  it  be  serum, 
pus,  or  blood,  accumulates  so  rapidly  or  in  such  quantity 
that  it  threatens  to  destroy  life  and  refuses  to  undergo 
absorption  by  ordinary  treatment,  it  is  the  duty  of  the  at- 
tendant to  tap  the  distended  sac.  It  is  an  operation  which 
gives  immediate  relief  by  removing  the  cause  of  the  urgent 
symptoms,  and  the  figures  which  I  shall  deduce  from  the 
cases  collected  prove  that  the  operation  itself  is  not  a  se- 
rious one.  How  long  we  are  to  trust  to  medical  means 
before  attempting  surgical  interference  must  be  left  to  the 
surgeon  or  physician  in  charge  of  each  case ;  but  I  greatly 
fear  the  tendency  is  to  wait  too  long  rather  than  to  operate 
too  early.  All  surgeons  see  cases  of  strangulated  hernia 
lost  because  of  valuable  time  having  been  squandered  in 
useless  attempts  at  taxis ;  so  patients  have  died  with  large 
pericardial  effusions,  because  the  fluid  was  not  pumped 
out  with  an  aspirator  before  the  hydrostatic  pressure  upon 
the  heart,  perhaps  enfeebled  by  disease,  became  intoler- 
able, and  the  central  organ  of  circulation  stopped.     That 

*  Journal  of  Anatomy  and  Physiology,  1871,  vol.  v.  p.  114. 


CASES  SUITABLE  FOR    OPERATION.  45 

this  picture  is  not  overdrawn  is  seen  by  the  records  of 
post-mortem  examinations,  where  many  fluidounces  of 
serum  have  been  found  in  the  distended  pericardium. 
Hayden,  in  his  work  on  diseases  of  the  heart  and  aorta, 
says  distinctly,  "  On  two  occasions  at  least  I  have  had 
reason  to  regret  the  omission  of  its  performance."* 

Some  writers  think  the  operation  unsuitable  for  cases 
of  hydro-pericardium  from  Bright's  disease,  and  contra- 
indicated  in  haemo-pericardium  as  well  as  in  purulent 
effusion  from  acute  osteo-myelitis  and  pyaemia,  because, 
they  say,  the  local  trouble  is  only  a  part  of  the  disease, 
and  there  is  something  more  which  the  operation  cannot 
benefit.  True  enough ;  but  if  it  is  the  local  effusion  w^hich 
menaces  the  life  of  the  patient  at  the  present  moment,  it 
is  the  enemy  that  must  be  opposed.  It  is  only  palliative, 
but  palliation  is  not  to  be  despised,  since  it  gives  time  for 
other  measures  to  be  adopted  that  may  reach,  at  least  in 
part,  the  more  distant  and  more  general  disease.  Admit 
"that  the  operation  is  only  palliative,  should  one  hesitate 
to  perform  it  because  the  patient  may  die  in  a  few  days 
or  weeks  of  some  concomitant  disorder?  If  paracentesis 
was  likely  to  cause  or  hasten  the  fatal  issue,  or  if  it  aug- 
mented the  sufl'ering  of  the  individual  while  doing  him 
no  good,  it  might  be  allowable  to  hesitate ;  but  that  such 
is  not  the  case  is  seen  by  intelligent  observation  in  all  parts 
of  the  world.  Who  would  decline  to  tap  an  immensely 
distended  abdomen  because  the  patient  suffered  at  the 
time  from  incurable  hepatic  disease,  or  to  draw  the  fluid 
from  the  pleura  because  the  patient  was  tuberculous  ? 

There  are,  undoubtedl}?-,  conditions  in  which  paracentesis 
of  the  pericardium  is  followed  by  much  more  brilliant 
results  than  in  others.     The  most  favorable  cases  are  those 

*  American  edition,  vol.  i.  p.  421. 


46  PARACENTESIS  OF  THE  PERICARDIUM. 

in  which  a  rapid  pericardial  efiusion  has  occurred  as  a 
complication  of  rheumatism.  Here  there  exists  a  disease 
that  usually  has  a  favorable  prognosis,  and  if  the  fibrino- 
serous  fluid  is  withdrawn  from  the  pericardium  the  danger 
of  the  heart  complication  is  averted,  and  the  patient  is 
saved  from  impending  dissolution. 

If  the  pericarditis  is  chronic,  or  accompanied  by  pulmo- 
nary or  pleural  disease,  there  is  less  chance  of  obtaining 
such  satisfactory  results,  though  many  cases  have  been  re- 
ported where  return  to  health,  as  far  as  the  pericardial  affec- 
tion was  concerned,  has  followed  the  performance  of  the 
operation  on  a  moribund  patient.  In  these  instances  the 
failure  of  perfect  convalescence  has  usually  been  due  to 
the  incurable  character  of  the  pulmonary  lesion,  or  to  the 
textural  changes  that  have  taken  place  in  and  around  the 
pericardium  during  the  continuance  of  the  inflammatory 
products  within  the  sac.  In  certain  instances  this  could 
have  been  averted  by  an  earlier  resort  to  operation.  When 
the  fluid  is  purulent  it  will  probably  be  necessary  to  repeat 
the  tapping,  but  I  cannot  see  why  it  would  not  be  advisable 
in  certain  cases  to  establish  a  continuous  drain,  as  is  done 
so  effectively  at  times  in  empyema.  This  matter,  however, 
must  be  discussed  later,  though  it  may  be  said  here  that  a 
second  tapping  does  not  appear  to  be  any  more  dangerous 
than  the  primary  operation.  In  fact,  it  might  be  looked 
upon  as  less  so,  since  there  is  great  probability  of  the 
pleura  having  become  adherent  after  the  first  operation. 

In  dropsy  of  the  pericardium  from  Bright's  disease,  it 
may  be  admitted  that  the  fluid  is  at  times  absorbed  with 
great  rapidity,  and  that  the  operation  does  not  affect  the 
primary  disease,  if  it  be  primary  and  not  secondary  to  the 
cardiac  trouble ;  but  still  I  say  tap,  if  there  be  evidence  of 
failing  circulation  and  respiration,  which  in  the  best  judg- 
ment of  the  attendant  depends  on  the  effusion. 


CASES  SUITABLE  FOR   OPERATION.  47 

Dr.  Pepper's  case  (ISTo.  57)  shows  this,  for  the  kidney 
symptoms  were  believed,  after  the  lapse  of  time  had  per- 
mitted observation,  to  be  due  to  the  pericarditis.  Before 
the  operation  the  urine  was  slightly  albuminous,  and  con- 
tained tube-casts,  while  some  weeks  subsequently  this 
symptom  had  entirely  disappeared.  What  a  diiferent  re- 
sult would  have  been  obtained  if  paracentesis  had  been 
rejected  in  this  instance,  because  there  was  a  suspicion  of 
Bright's  disease  underlying  the  pericarditis  ! 

In  hemorrhagic  pericarditis  the  prognosis  becomes  very 
unfavorable,  but  not  hopeless,  if  we  credit  the  cases  of 
Kyber,  Karawagen,  and  others.  Where  there  is  a  pysemic 
causation  the  result  must  be  still  more  doubtful,  and  yet 
in  even  these  instances  the  operation  seems  to  me  justi- 
fiable, provided  the  urgent  dyspnoea  and  depression  ap- 
pears to  depend  on  the  obstruction  to  the  circulation. 

I  am  inclined  to  go  even  a  step  farther,  and  suggest  the 
emploj-ment  of  paracentesis  in  those  rare  cases  of  pneumo- 
hydro-pericarditis  which  occasionally  present  themselves 
for  treatment.  A  most  interesting  case  of  this  kind  has 
been  reported*  by  Dr.  J.  F.  Meigs,  in  which  I  should  have 
been  induced,  I  think,  to.Jta»e  performefd  the  operation  of 
tapping.  The  presence  of  air  and  fluid  in  the  pericar- 
dium was  diagnosticated  before  death.  At  the  autopsy 
there  were  found  evidences  of  pericarditis,  with  air  and 
eight  to  twelve  fluidounces  of  reddish-brown  liquid  in  the 
sac.  The  air  had  entered  by  an  opening  leading  into  the 
cesophagus,  due.  Dr.  Meigs  thinks,  to  "  an  efibrt  of  nature 
to  evacuate  the  diseased  contents  of  the  pericardium, 
as  happens  in  the  case  of  empyema  when  the  latter  is 
cured  by  natural  processes."  As  the  patient  had  had 
double  pleurisy  and   subsequent  pericarditis,  he   thinks 

*  American  Journal  of  Medical  Sciences,  January,  1875,  p.  94. 


48  PARACENTESIS   OF   THE   PERICARDIUM. 

tliis  explanation  should  be  accepted  rather  than  the  sup- 
position that  an  accidental  ulceration  of  the  a3sophagu8 
should  have  occurred  coincidently.  If  the  case  is  inter- 
preted in  the  former  way,  it  is  certainly  a  strong  argument 
for  the  adoption  of  paracentesis  in  pericardial  effusions ; 
and  then  it  may  be  advanced  that  tapping,  even  after 
pneumo-pericardium  had  occurred,  would  have  given  an 
opportunity  for  closure  of  the  abnormal  orifice. 

After  it  has  been  decided  that  the  operation  is  a  proper 
mode  of  treating  the  patient  under  consideration,  it  is  not 
justifiable  to  delay  a  long  time  before  resorting  to  it.  In 
very  chronic  cases  the  immediate  danger  of  delay  may  be 
less,  but  there  is  constantly  going  on  a  succession  of  patho- 
logical changes,  such  as  thickening  of  the  membrane,  ad- 
hesion of  the  pericardial  tissue  to  the  structures  external  to 
it,  chronic  pulmonary  congestion,  and  obstruction  to  the 
venous  return  from  the  head,  due  to  the  hydrostatic  press- 
ure on  the  right  auricle  and  descending  vena  cava.  On 
the  other  hand,  undue  haste  in  operating  on  acute  effusions 
is  to  be  deprecated,  because  large  effusions  at  times  disap- 
pear Avith  great  rapidity  under  medical  treatment.  Still,  it 
appears  that  more  harm  is  liable  to  result  from  delay  than 
from  an  operation  done  early,  if  due  care  be  taken  in  the 
manner  of  performing  the  operation.  The  danger  of  delay- 
ing the  removal  of  the  fluid  has  not  only  reference  to  the 
possibility  of  sudden  asphyxia,  but  also  to  the  occurrence  of 
myocarditis  and  fatty  degeneration  of  the  muscular  wall  of 
the  heart.  The  existence  of  inflammation  or  degeneration 
of  the  cardiac  muscle  is  more  often  found  in  purulent  and 
hemorrhagic  cases  than  in  others,  but  it  is  liable  to  occur 
in  all  instances.  Whether  it  be  due  to  pressure  interfering 
with  the  blood  supply  of  the  organ,  or  to  the  increased  work 
thrown  upon  the  heart,  matters  little,  the  fact  remains  that 
such  lesions  do  occur  as  accompaniments  of  pericarditis. 


METHODS  OF  OPERATING.  49 


CHAPTER    lY. 

METHODS    OF   OPERATING. 

"When  the  operation  first  suggested  itself  to  observ-ers 
and  writers,  the  question  that  immediately  arose  was  as  to 
the  method  of  reaching  the  distended  pericardium.  The 
earlier  authorities,  such  as  Senac,  Skielderup,  and  Laennec, 
proposed  trephining  the  sternum  above  the  xiphoid  carti- 
lage ;  but  this  is,  of  course,  not  to  be  thought  of  at  the 
present  day,  for  the  operation  would  be  much  more  serious 
if  complicated  with  the  suppuration  that  must  needs  re- 
sult from  such  a  procedure.  Others  suggested  that  a  pre- 
liminary incision  should  be  made  at  the  point  selected,  and 
the  tissues  divided  layer  by  layer,  as  in  herniotomj^,  until 
the  pericardium  should  be  reached,  when  a  trocar  was  to 
be  thrust  into  it.  Others  thrust  the  ordinary  hydrocele 
trocar  directly  into  the  sac. 

At  our  day  aspiration  is  the  method  preferred  to  all 
others.  In  this  method  there  is  no  danger  of  osseous  sup- 
puration retarding  convalescence  by  the  possible  burrow- 
ing of  pus  among  the  thoracic  tissues;  there  is  no  long 
incision  which  might  cause  hemorrhage  from  injury  to 
the  internal  mammary  artery  or  one  of  its  branches ;  the 
entire  amount  of  fluid  can  be  drawn  out,  there  is  little 
danger  of  the  pericardial  fluid  dribbling  into  the  pleural 
sac  if  it  should  happen  to  be  punctured,  and  the  fine 
needle  will  do  little  harm  even  if  it  pass  through  the  edge 
of  the  lung  or  strike  the  ventricular  wall  itself. 

In  addition  to  the  advantao:es  mentioned,  the  entrance 


50  PARACENTESIS   OF   THE  PERICARDIUM. 

of  air  is  prevented,  and  thus  the  liability  to  the  occurrence 
of  suppurative  pericarditis  subsequent  to  tapping  is  re- 
duced to  a  minimum,  and  the  wound  is  such  a  trivial  one 
that  it  amounts  to  nothing,  giving  little  pain  at  tlie  time 
of  operation  and  soon  healing,  so  that  an  autopsy,  even 
if  made  early,  shows  only  a  small  ecchymotic  spot  in  the 
tissues.  The  risk  of  wounding  the  mammary  artery  is  re- 
duced to  a  mere  chance,  because  of  the  diminutive  needle 
that  can  be  used  w^hen  suction  power  is  employed. 

If  a  trocar  of  ordinary  kind  is  used,  the  thickened  and 
hard  pericardium  may  be  pushed  in  front,  because  of  its 
loose  attachment  to  the  thoracic  parietes ;  but  the  needle 
of  the  aspirator  can  be  thrust  gradually  through  the  tissues 
without  the  same  probability  of  displacing  the  sac  .walls. 
Again,  the  vacuum  attached  to  the  needle  shows  the  sur- 
geon the  very  moment  the  sac  is  entered,  because  the  fluid 
at  once  fills  the  tube  and  is  seen  flowing  towards  the  re- 
ceiver. This  is  a  matter  of  paramount  importance,  since 
otherwise  the  needle  might  be  pushed  onward  into  the 
ventricle. 

As  we  have  stated  that  aspiration  is  to  be  adopted 
in  performing  paracentesis  pericardii,  it  may  be  asked 
whether  the  ordinary  sharp-pointed  needle  or  the  trocar 
and  canula,  furnished  with  the  aspirator  as  sold  in  the 
shops,  is  the  better  instrument  for  perforating  the  peri- 
cardial membrane.  There  is  an  objection  to  having  the 
pointed  needle  or  the  sharp-edged  canula  within  the  sac 
when  the  fluid  has  been  partly  withdrawn,  as  there  is  a 
possibility  of  the  heart  becoming  scratched.  - 

There  has  been  described*  by  Fitch  the  so-called  dome- 
shaped  trocar,  in  which  a  blunt  or  "  round-ended"  fenes- 
trated canula  slides  within  the  penetrating  needle.    (Fig.  5.) 

*  New  York  Medical  Journal,  April,  1875. 


METHODS   OF  OPERATING. 


51 


This,  if  made  small  and  adapted  to  the  aspirator,  would 
be  an  admirable  instrument.    In  the  "  iN^ew  York  Medical 


Fig.  5. 


Fig.  6. 


Fitch's  tiocar. 


Koberts's  trocar. 


Journal"  for  April,  1877,  page  384,  I  have  described  an 
aspirating  trocar  which  is  figured  above.     (Fig.  6.)     It 


52  PARACENTESIS   OF   THE   PERICARDIUM. 

consists  of  a  small,  needle-pointed  cylinder,  within  which 
slides,  on  Fitch's  principle,  a  canula  attached  to  the  air- 
pump.  The  canula  at  the  end  is  made  flexible  by  a  spiral, 
and  when  it  is  thrust  out  beyond  the  end  of  the  needle 
curves  downward ;  but  when  it  is  pulled  backward  the  end 
becomes  straight,  and  is  entirely  concealed  within  the 
outer  puncturing  needle.  The  extremity  of  the  canula  is 
pierced  with  a  hole  and  there  are  also  two  other  fenestras 
just  above,  to  give  exit  to  the  fluid.  The  method  of  using 
it  is  as  follows :  the  canula  is  drawn  back  until  its  flexible 
end  is  hidden  within  the  needle,  and  the  hose  from  the 
pump  is  attached  to  a  small  tube  fixed  at  a  right  angle  to 
the  posterior  extremity  of  the  canula.  The  outer  punc- 
turing instrument  is  thrust  into  the  integument,  and  the 
operator  immediately  causes  the  vacuum  to  exert  suc- 
tion through  the  internal  canula;  consequently  a  flow  of 
serum  shows  the  moment  that  the  instrument  has  entered 
the  cavity  of  the  pericardium.  The  surgeon  immediately 
withdraws  the  needle  a  little,  and  thrusts  the  internal  flex- 
ible canula  into  the  sac,  so  that  the  point  of  the  trocar  is 
guarded,  and  there  hangs  in  the  sac  a  blunt,  flexible  tube, 
against  which  the  heart  can  strike  with  impunity.  This 
aspirating  trocar  is  innocuous  to  the  heart,  and  the  curved 
extremity  allows  suction  to  be  exerted  to  a  considerable 
extent  at  the  very  bottom  of  the  pericardial  cavity.  If 
the  canula  becomes  plugged  with  flakes  of  lymph,  the 
handle  can  be  unscrewed,  the  inner  portion  withdrawn, 
and  the  hose  attached  to  the  end  of  the  penetrating  needle, 
which  then  acts  as  a  large,  ordinary  aspirating  needle. 

Dr.  Pepper,  after  operating  on  the  case  reported  in 
the  table,  had  made  a  delicate  double  canula,  the  inner 
tube  of  which  is  furnished  with  a  fine  needle-point.  The 
movements  of  the  inner  tube  are  regulated  by  a  button 
which  moves  along  a  slot  in  the  outer  tube.     After  intro- 


METHODS  OF  OPERATING.  53 

duction  the  inner  tube  is  withdrawn  until  its  point  is 
sheathed.* 

When  I  first  described  my  trocar,  mentioned  above,  I 
was  only  acquainted  with  Fitch's  trocars  of  large  size  as 
used  in  ovarian  dropsy,  but  subsequently  I  found  that  he 
had  described  small  capillary  instruments,  such  as  would 
be  required  in  paracentesis  of  the  pericardium.  These,  it 
seems  to  me,  furnish  us  with  the  most  perfect  trocar  for 
the  purpose. 

The  capillary  trocars  of  Southey,  invented  for  draining 
the  serum  from  oedematous  limbs,  might,  if  long  enough, 
be  used  where  it  was  thought  proper  to  establish  a  con- 
tinuous flow  of  fluid  from  the  pericardium.  I  merely 
mention  them  to  the  reader  because  they  have  been  used 
for  paracentesis  abdominis,t  but  do  not  think  the  occasion 
for  their  use  in  pericarditis  is  likely  to  arise. 

In  performing  the  operation,  Potain's  aspirator  with  a 
vacuum  jar  (Fig.  7)  is  best,  because  the  vessel  can  be  emptied 
of  air  before  the  trocar  is  introduced,  and  there  is  then  no 
shaking  produced  by  pumping  after  the  pericardium  has 
been  perforated.  The  stop-cock  should  be  turned  so  as  to 
allow  the  atmospheric  pressure  to  exert  its  force,  as  soon 
as  the  fenestra  of  the  trocar  is  buried  beneath  the  inte2:u- 
ment.  Thus  the  operator  is  apprised  of  the  entrance  of 
the  trocar  into  the  fluid  collecti5n. 

If  the  fluid  reaccumulates  I  can  see  no  great  objection 
to  repeating  the  operation  again  and  again,  as  was  done 
in  Gooch's  and  Bouchut's  cases  (Nos.  43,  48).  Roger 
looks  upon  repeated  operations  with  disfavor,!  but  the 
evidence  deduced  from  the  cases  tabulated  shows   that 


*  The  Medical  News  and  Library,  Philadelphia,  March,  1878,  p.  40. 
f  Monthly  Abstract  of  Medical  Science,  November,  1878. 
X  Bull,  de  I'Academie  de  Medecine,  1875,  p.  1283. 


54 


PARACENTESIS  OF  THE  PERICARDIUM. 


there  is  no  more  risk  in  second  than  in  first  tappings,  for 
in  the  cases  where  the  operation  was  repeated  there  is 
no  testimony  that  the  procedure  did  harm.  In  many  in- 
stances the  patient  subsequently  died,  I  admit,  but  the 
time  after  operation  was  on  an  average  too  long  to  attrib- 
ute the  result  to  the  paracentesis;  and,  moreover,  the  re- 


Potain's  aspirator. 


accumulation  was  as  a  rule  due  to  the  fact  that  there  was 
some  complication  rendering  repeated  eftusions  probable. 
Aspiration  is  repeated  in  pleuritis  and  synovitis,  and  so  it 
may  be  in  pericarditis  if  there  is  a  secondary  efiusion. 

Some  operators  have  injected  iodine  into  the  sac,  after 
the  withdrawal  of  the  fluid,  with  the  idea  of  modifying 
the  secreting  surfaces,  or  of  inducing  adhesion  of  the 
layers  of  pericardium.  Aran's  successful  case  (^o.  19), 
in  which  tapping  and  injection  J«sag  done  twice,  shows  '^-"■h- 
that  this  is  not  improper  treatment.     Kyber  considered* 


*  Monthly  Ketrospect  of  Medical  Sciences,  Edinburgh,  March,  1848. 
See  also  Guentlier's  Blutigen  Operationen,  IV.  iii. 


METHODS    OF  OPERATING.  55 

adhesion  the  method  of  cure,  because  he  found  it  had 
occurred  in  tliree  successful  j^aracenteses  where  autopsies 
were  obtained  long  afterwards;  and  the  fact  that  Pepper's 
case  showed  close  and  universal  adhesions  proves  the 
probable  correctness  of  the  earlier  operator's  view. 

Injection  was  adopted  by  Aran  as  he  had  found  it 
satisfactory  in  pleural  effusions,  and  others  have  adopted 
the  procedure.  Roger  does  not  think  it  applicable,*  be- 
cause there  is,  he  believes,  danger  of  suppuration  in  the 
sac,  and  of  effusion  of  pus  into  the  mediastinum,  and  be- 
cause there  is  not  the  same  tendency  as  in  pleurisy  to  re- 
traction and  approximation  of  the  two  layers.  ]\Iy  own 
opinion  is,  that  since  we  have  the  aspirator,  instead  of  the 
old  trocar,  and  can  prevent  the  entrance  of  air,  the  injec- 
tion of  iodine  is  not  indicated  as  it  was  formerly,  perhaps, 
when  the  admission  of  air  was  liable  to  change  a  serous 
pericarditis  into  a  purulent  one.  After  simple  tapping  ad- 
hesion will  very  probably  occur,  unless  the  effusion  be  due 
to  a  passive  dropsy,  in  which  case  adhesion  is  not  neces- 
sary to  a  cure ;  hence  injections  are  not  required  either  in 
inflammatory  effusions,  where  adhesion  w^ill  be  apt  to  take 
place  without  any  aid,  nor  in  hydro-pericardium,  where  re- 
lief of  the  condition  depends  on  other  factors  than  adhesion. 
The  simple  withdrawal  of  the  fluid,  with  repeated  opera- 
tions if  reaccumulation  take  plaice,  is  the  proper  course  to 
pursue.  Should  the  pericardial  contents  become  purulent, 
or  if  I  were  afraid  of  this  contingency,  then  injections  of 
carbolized  w^ater  would  be  preferred  to  an  iodized  solu- 
tion. 

This  brings  us  to  the  management  of  purulent  pericar- 
ditis, which  is  probably  never  primary,  but  secondary  to 
some  other  form  of  eftusion.     Examination  of  the  cases 

*  Op.  cit.,  p.  1282. 


56  PARACENTESIS   OF  THE   PERICARDIUM. 

piiMislicd  will  show  that  the  operation  has  at  times  been 
done  for  existing  purulent  effusion,  while  at  other  times 
the  effusion  was  at  first  serous,  but  subsequently  became 
purulent  from  admission  of  air,  or  from  some  unknown 
factor,  probably  due  to  the  paracentesis.  How  are  such 
cases  to  be  treated  ?  At  first  there  is  no  doubt  that  simple 
tapping  is  to  be  resorted  to,  supplemented  possibly  wdth 
injection  and  washing  out  of  the  cavity  with  carbolic  acid 
solutions  of  the  strength  of  one  to  twenty  or  thereabouts. 
If  the  pus  reaccumulate,  it  is  almost  impossible  for  it  to 
become  absorbed,  and  it  will  increase  in  quantity  and 
cause  pathological  alterations  in  the  pericardium  and  sur- 
rounding structures.  Hence  I  would  advise  a  repetition 
of  the  operation  with  carbolized  injection  somewhat  in 
the  manner  of  Callender's  hyperdistention  of  abscesses, 
though  of  course  this  could  not  be  practised  with  the 
amount  of  pressure  justifiable  in  ordinary  situations.  If 
repeated  tapping  becomes  necessary  from  the  rapid  secre- 
tion of  pus  causing  imminent  danger,  I  can  see  no  reason 
for  objecting  to  an  opening  being  made  to  secure  perma- 
nent drainage.  We  know  the  results  produced  by  im- 
prisoned pus ;  we  know  that  purulent  pericarditis  practi- 
cally means  death  unless  it  is  removed  by  absorption  or 
operation,  to  permit  of  adhesion  taking  place.  Again,  we 
see  reported  instances  where  pericardial  fistulse  have  been 
established  by  nature  without  deleterious  results.  Wyss 
has  described*  a  case  where  a  rib  was  worn  away  and  a 
fistule  established  that  remained  patent  until  death  oc- 
curred years  afterwards.  Villeneuve  (see  Case  47)  had  a 
fistulous  track  remain  for  a  number  of  months  after  para- 
centesis of  the  pericardium,  but  it  finally  closed. 

These  facts,  coupled  with  the  surgical  axiom  that  pus 

*  Zienissen's  Cyclopaedia  of  Medicine,  vol.  vi.  p.  564. 


METHODS  OF  OPERATING.  57 

should  always  be  allowed  free  egress,  even  if  the  abscess 
be  in  so  vital  an  organ  as  the  brain,  influences  me  in  my 
opinion  that  purulent  pericarditis  demands  treatment  iden- 
tical with  purulent  pleuritis.  I  have  seen  such  excellent 
results  follow  the  introduction  of  drainage-tubes  into  the 
pleural  sac  for  the  treatment  of  empyema,  that  I  would 
recommend  a  similar  line  of  action  in  the  cases  under  dis- 
cussion. Let  a  drainage-tube  be  placed  in  the  pericardial 
sac,  and  let  the  surgeon  daily  wash  out  the  cavity  with 
disinfecting  solutions.  This  resort  is  to  be  adopted  of 
course  only  after  tapping  has  been  found  unsuccessful.  It 
seems  less  dangerous  than  repeated  tapping,  because  it  is 
possible  that  the  heart  may  become  adherent  to  the  pa- 
rietal layer  between  two  successive  operations,  and  sustain 
injury  from  the  puncturing  instrument. 

I  am  aware  that  this  opinion  differs  from  that  of  Roger 
and  of  Pepper,  and  would  most  probably  be  looked  upon 
as  hazardous  by  many.  In  an  article  written*  in  1876,  I 
held  this  opinion,  and  the  subsequent  study  of  the  cases  of 
Villeneuve,  Juergensen,  and  Viry,  which  I  had  not  then 
seen,  and  other  facts  bearing  on  the  subject,  serve  only  to 
confirm  me  in  this  belief.  I  admit  that  deductions  from 
pleural  conditions  must  be  received  with  the  understand- 
ing that  there  are  two  lungs,  each  of  which  can  supple- 
ment the  other,  while  there  is  only  one  central  organ  of 
circulation ;  still  the  thickening  of  pericardium,  the  mac- 
eration and  disintegration  of  the  cardiac  muscle,  the  lia- 
bility to  spontaneous  evacuation,  all  convince  me  that  the 
drainage-tube,  or,  if  you  choose,  free  drainage,  is  a  better 
alternative.  Whether  or  not  the  strict  antiseptic  dressing 
of  Lister  should  be  insisted  upon  I  leave  to  the  judgment 
of  the  operator.     The  object  to  be  attained  is  the  restora- 


*  New  York  Medical  Journal,  December,  1876. 
5 


58  PARACENTESIS  OF   THE  PERICARDIUM. 

tion  of  the  patient  to  at  least  a  fair  degree  of  health,  and 
that  universal  pericardial  adhesion  is  not  incompatible 
with  this  is  proved  by  many  pathological  examinations. 

THE    POINT    OF    PUNCTURE. 

A  survey  of  the  recorded  cases  of  paracentesis  of  the 
pericardium  will  show  that  there  is  a  considerable  diver- 
sity of  opinion  as  to  the  best  point  at  which  the  puncture 
should  be  made.  The  pericardium  when  distended  may 
be  reached  by  needles  thrust  in  at  several  points,  as  can 
be  comprehended  if  reference  be  made  to  the  anatomical 
description  of  the  membrane.  There  are,  however,  com- 
plications arising  from  the  needle's  introduction  at  certain 
points  and  not  at  others,  that  make  a  careful  study  of  this 
question  of  paramount  importance. 

When  the  puncture  is  made  high  up  there  is  great  lia- 
bility of  w^ounding  the  auricle,  because  the  pericardium 
cannot  be  distended  at  its  upper  part  as  it  can  at  the  lower. 
This  accident  is  to  be  avoided,  since  wounds  of  the  auricle 
are  of  grave  prognosis,  much  more  so  than  wounds  of  the 
ventricles,  which  indeed  seem  to  be  of  little  moment. 
Again,  if  the  aspirating  instrument  is  introduced  too  low 
down  it  may  injure  the  diaphragm,  or  not  enter  the  peri- 
cardium at  all.  A  point  selected  too  far  to  the  left  en- 
dangers the  lung,  and  if  located  about  a  quarter  of  an 
inch  from  the  border  of  the  sternum  may  place  the  integ- 
rity of  the  internal  mammarj^  artery  in  jeopardy.  Thus 
it  is  evident  that  a  point  is  to  be  elected,  free  from  com- 
plicating sequences,  which  gives  ready  and  perfect  access 
to  the  pericardial  cavity. 

Let  us  first  consult  what  has  been  said  by  previous 
writers  on  the  subject,  and  endeavor  afterwards  to  deter- 
mine which  point  is  to  be  recommended  for  its  safety, 
convenience,  and  efficiency.     Larrey  thought  the  proper 


POINT  OF  PUNCTURE.  59 

position  was  to  be  found  between  the  xiphoid  cartilage  and 
the  cartilages  of  the  ribs  of  the  left  side  ;*  while  Trous- 
seau preferred  the  fifth  or  sixth  interspace  close  to  the 
sternum,  and  said  that  if  the  cartilages  were  too  close  to 
admit  the  trocar,  a  portion  of  the  cartilage  might  be 
trimmed  away.  A  somewhat  similar  level  should  be 
chosen  according  to  the  judgment  of  Dieulafoy,  who 
advocates  the  fourth  or  fifth  interspace,  but  goes  to  the 
distance  of  about  six  centimetres  from  the  left  edge  of 
the  sternum. t  He  selects  this  position  because  he  found 
by  experiment  that  the  maximum  transverse  diameter  of 
the  distended  pericardium  coincided  with  the  fourth  inter- 
space or  fifth  rib,  and  that  it  is  here  that  the  notch  in  the 
edge  of  the  left  lung  is  situated;  hence  the  danger  of 
piercing  the  lung  is  reduced  to  a  minimum.  The  point 
recommended  by  Eoger  very  nearly  coincides  with  the 
second  one  of  Dieulafoy.  He  states  that  the  proper  loca- 
-tion  for  operation  is  in  the  fifth  interspace,  about  mid- 
way between  the  left  nipple  and  the  sternum,  but  a 
little  nearer  the  former  than  the  latter  landmark.^  If  the 
heart  is  hypertrophied,  and  therefore  situated  at  the  lower 
part  of  the  sac,  or  if  held  there  by  adhesions  which 
prevent  its  being  left  in  its  usual  position  when  the  fluid 
accumulation  pushes  the  pericardium  and  diaphragm 
down,  it  may  be  advisable  to  tap  in  the  sixth  intercostal 
space.  Of  this  physical  condition  of  the  heart  the  sur- 
geon must  endeavor  to  become  cognizant  before  the  oper- 
ation is  instituted.  Sibson's  vote  would  likewise  be  in 
favor  of  the  fifth  interspace,  for  he  says§  the  trocar  should 
penetrate  above  the  upper  edge  of  the  sixth  cartilage, 

*  Dieulafoy  on  Pneumatic  Aspiration,  pp.  222-224. 

t  Op.  cit.,  pp.  230,  231. 

X  Bull,  de  I'Acad.  de  Med.,  p.  1279. 

§  Keynolds's  System  of  Medicine,  vol.  iv.  p.  436. 


QO  PARACENTESIS  OF  THE  PERICARDIUM. 

more  than  an  inch  within  the  mammary  line,  and  be  di- 
rected slightly  downwards  so  as  to  avoid  the  heart,  which, 
in  its  healthy  condition  as  to  size,  etc.,  has  its  lower  border 
above  the  level  of  the  fifth  space.  If  the  heart's  beat 
is  felt  at  a  lower  level  than  usual,  he  advises  the  in- 
sertion of  the  trocar  in  the  epigastric  region,  between  the 
ensiform  cartilage  and  the  seventh  costal  cartilage.  This 
is  justifiable,  because  the  lower  border  of  the  fully  dis- 
tended sac  is  usually  at  about  the  level  of  the  lower  end 
of  the  xiphoid  appendix ;  hence,  tapping  may  be  done  at 
the  middle  of  this  part  of  the  sternum,  in  the  depression 
between  it  and  the  costal  cartilages.  Agnew  considers* 
the  sixth  interspace,  one  inch  to  the  left  of  the  margin  of 
the  sternum,  as  the  most  accessible  route.  Braune  says 
the  safest  position  for  puncture  in  order  to  avoid  the  pleura 
is  in  the  upper  angle,  between  the  left  edge  of  the  sternum 
and  the  fifth  cartilage, f  which  would  be  in  the  fifth  inter- 
space, close  to  the  sternum.  Adhesion  of  the  pleura  may 
not  occur  for  a  long  time  after  the  presence  of  large  effu- 
sion ;  hence  he  thinks  it  well  to  keep  near  the  sternum. 

If  we  consider  the  points  recommended,  it  is  evident  that 
they  may  be  reduced  in  a  general  way  to  four  different 
localities, — the  fourth  interspace,  the  fifth  interspace,  the 
sixth  interspace,  and  the  fossa  between  the  xiphoid  ap- 
pendix and  the  cartilages  of  the  false  ribs  as  they  ascend 
obliquely  to  form  the  lower  part  of  the  thoracic  wall. 
After  having  determined  which  locality  is  best,  the  oper- 
ator, if  he  choose  either  of  the  first  three,  must  decide 
whether  it  is  preferable  to  keep  within  the  line  of  the 
mammary  artery,  or  to  go  outward  towards  the  nipple. 
The   objection   to   puncturing    near  the   sternum   is   the 


*  Agnew's  Surgery,  vol.  i.  p.  348. 

f  Topographical  Anatomy,  English  edition,  p.  lOG. 


POINT  OF  PUNCTURE. 


61 


vicinity  of  the  mammary  artery ;  but,  on  the  other  hand, 
the  probability  of  piercing  the  pleura,  if  a  point  farther  to 
the  left  be  chosen,  renders  the  latter  position  to  some 
extent  objectionable. 

I  shall  discuss  these  points  in  order,  and  endeavor  to 
decide  as  to  their  relative  merits.  To  make  the  subject 
intelligible,  I  have  introduced  the  accompanying  figure 

Fig.  8. 


(Fig.  8),  which  shows  the  seven  points  mentioned  by  the 
authors  quoted.  Each  point  is  indicated  by  a  cross,  to 
which  is  affixed  the  initial  of  the  writer  who  recommends 
it ;  when  he  gives  two  points  from  which  the  operator  is 
to  choose,  the  initial  letter  appears  in  two  places. 

An  examination  of  the  figure  shows  a  fact  that  might 
not  suggest  itself  to  one  who  is  not  in  the  habit  of  making 
accurate  thoracic  explorations.  It  is  this,  that  the  carti- 
lages before  joining  the  sternum  curve  upwards,  and  that 


62  PARACENTESIS  OF  THE  PERICARDIUM. 

necessarily  the  intercostal  spaces  do  the  same ;  hence  a 
puncture  made  in  one  interspace  near  the  sternum  cor- 
responds in  level  with  a  puncture  made  in  the  interspace 
above,  two  or  three  inches  to  the  left  of  the  breast-bone. 
Again,  it  must  be  recollected  that  the  interspaces  become 
very  narrow  as  they  approach  the  median  line,  and  that 
the  fifth  and  sixth,  and  sixth  and  seventh  cartilages  are 
frequently  joined  by  cartilaginous  bands  of  varying  width. 
The  seven  points  marked  are  in  three  instances  close  to 
the  sternum  and  within  the  ordinary  line  of  the  internal 
mammary  artery,  in  three  instances  far  to  the  left  of  the 
artery,  and  in  one  case  between  these  two  limits.  The 
reason  for  selecting  the  vicinity  of  the  sternum  is  to  avoid 
puncturing  the  pleura,  which  is  reflected  upon  the  front  of 
the  pericardium,  but  does  not  extend  to  the  left  edge  of 
the  sternum. 

Of  the  three  internal  points,  I  regard  that  between  the 
ensiform  appendix  and  the  seventh  cartilage  the  best,  be- 
cause the  two  above  are  located  in  the  narrowest  portions 
of  the  intercostal  spaces,  so  that  it  is  difficult  at  times  to 
push  a  trocar  or  needle  between  the  cartilages.  Even 
if  the  instrument  would  pass  it  would  be  almost  impossi- 
ble to  determine  the  proper  point  of  skin  at  which  to 
introduce  it,  unless  the  preliminary  incision,  suggested  by 
Trousseau,  was  made,  but  which  I  reject,  as  mentioned 
under  the  methods  of  operating.  In  a  dried  specimen, 
before  me  as  I  write,  there  is  only  sufficient  room  in  these 
situations,  and  for  an  inch  or  more  outw^ards,  to  allow  a 
large  pin  to  be  passed  between  the  cartilages.  There  was 
possibly  more  space  before  desiccation,  but  certainly  not 
sufficient  to  render  this  an  available  point  for  paracentesis. 

An  aspirating  needle  could,  doubtless,  in  a  young  sub- 
ject, be  thrust  through  the  cartilage,  but  a  disk  of  car- 
tilage would  plug  the  instrument  and  prevent  the  fluid 


POINT  OF  PUNCTURE.  63 

flowing ;  then  the  operator  would  be  likely  to  abandon  the 
operation  or  thrust  the  needle  onward  into  the  heart  itself. 
In  the  case  of  Ponroy  (Case  ISTo.  33)  the  cartilage  was 
struck,  though  I  do  not  know  that  he  punctured  in  this 
position,  and  a  disk  w^as  found  in  the  end  of  the  needle  on 
its  withdrawal ;  fortunately,  there  was  room  for  the  escape 
of  fluid  by  the  lateral  fenestra.  Moreover,  the  pleura 
approaches  the  edge  of  the  breast-bone  so  closely  that  it 
would  very  probably  be  injured,  and  if  this  occur  the  chief 
advantage  of  puncturing  near  the  sternum  is  lost.  It  is 
interesting,  however,  to  know  that  Baizeau  after  his  ex- 
periments recommends  the  fifth  space  close  to  the  sternum, 
and  believes  the  pleura  would  seldom  be  wounded.*  There 
is,  however,  plenty  of  space  between  the  xiphoid  appendix 
and  seventh  costal  cartilage,  the  fossa  is  quite  easily  felt 
as  a  rule,  and  it  is,  moreover,  lower  down,  and  conse- 
quently nearer  the  bottom  of  the  pericardial  sac  and  far- 
ther from  the  ventricle  than  the  other  points. 

If  this  point  is  selected,  the  trocar  should  be  entered 
close  to  the  ensiform  cartilage  to  avoid  as  far  as  possible 
a  small  branch  of  the  mammary  arter}^  which  traverses 
this  fossa  along  its  internal  surface.  The  pleura  would 
not  be  likely  to  be  wounded,  because  it  turns  oW  to  the 
left  before  it  extends  down  as  far  as  the  xiphoid  fossa. 
There  is  a  possibility,  however,  of  the  puncture  being 
made  too  low  down  and  the  needle  passing  directly  into 
the  abdominal  cavity,  for  the  diaphragm  is  attached  to 
the  ensiform  appendix  and  margin  of  the  costal  cartilages, 
and  then  arches  upwards,  keeping  for  a  time  close  to  the 
sternum.  Hence,  if  the  needle  be  not  introduced  as  high 
up  in  the  xiphoid  fossa  as  possible,  it  may  pass  below  the 
attachment  of  the  diaphragmatic  arch,  or,  if  entering  the 


*  Gaz.  Hebdora.  de  Med.  et  de  Chir.,  1868,  p.  566. 


64  PARACENTESIS   OF   THE  PERICARDIUM. 

pericardium,  may  by  penetratiiio;  deeper  project  through 
the  posterior  wall,  and  go  through  the  arch  of  the  dia- 
phragm into  the  abdomen  and  wound  the  liver.  When 
the  pericardium  contains  sufficient  fluid  to  distend  its 
walls  and  to  depress  the  diaphragm,  and  when  the  patient 
is  inspiring,  there  is  of  course  less  danger  to  be  anticipated 
from  these  anatomical  relations. 

A  locality  between  the  three  internal  and  the  three  ex- 
ternal points  is  the  one  suggested  by  Agnew ;  but,  though 
I  hesitate  to  diifer  from  so  distinguished  an  anatomist  and 
surgeon,  I  believe  it  to  be  bad.  In  the  first  place,  it  ap- 
proaches too  near  the  cartilaginous  band,  which  usually 
joins  the  sixth  and  seventh  cartilages,  and,  in  the  second 
place,  in  an  instance  where  I  tried  it  experimentally,  the 
musculo-phrenic  artery,  one  of  the  terminal  branches  of 
the  internal  mammary,  and  a  vessel  of  considerable  size, 
lay  in  dangerous  proximity  to  the  puncturing  instrument. 
The  distance  between  the  puncture  and  the  vessel  was  one- 
eighth  of  an  inch.  This  may  surprise  the  reader  until  it 
is  recollected  that  the  lower  part  of  the  breast-bone  tapers 
and  that  the  musculo-phrenic  artery  runs  obliquely  down- 
wards and  outwards;  hence  "one  inch  to  the  left  of  the 
margin  of  the  sternum"  is  not  outside  the  vessel.  I  be- 
lieve that  the  pericardial  cavity  would  be  reached  by  such 
a  puncture,  but  the  objections  mentioned  serve  to  condemn 
it  in  my  mind. 

Let  us  next  discuss  the  three  external  points  delineated 
in  the  wood-cut.  The  one  in  the  fourth  interspace  is  too 
high  up,  while  that  in  the  sixth  space  is  probably,  for  most 
cases,  too  low  down,  especially  if  it  be  carried  farther  to 
the  left  than  the  junction  of  the  sixth  rib  with  its  cartilage. 
On  these  accounts  I  prefer  that  in  the  fifth  intercostal  space, 
which  is  situated  very  near  the  normal  apex  beat  of  the 
heart,  close  to  and  above  the  junction  of  the  sixth  rib  with 


POINT  OF  PUNCTURE.  65 

the  coiTesponcling  cartilage.  It  is  here,  as  well  as  in  the 
fourth  space,  that  the  notch  in  the  edge  of  the  left  lung 
occurs,  which  would  prevent  its  heing  wounded  even  if 
the  pericardial  effusion  had  no  tendency  to  push  the  lung 
away  laterally. 

The  seven  points  given  as  proper  for  tapping  the  peri- 
cardium have  now  been  reduced  to  two,  viz. :  the  fossa  be- 
tween the  ensiform  and  the  costal  cartilages  of  the  left  side, 
and  the  fifth  interspace,  near  the  junction  of  the  sixth  rib 
with  its  cartilage.  Is  there  anything  in  favor  of  one  of 
these  over  and  above  the  other?  A  glance  will  show  that 
the  two  positions  are  practically  on  the  same  level,  but  the 
diaphragm  comes  higher  at  the  middle  line  than  it  does 
laterally;  hence  the  former  point  of  puncture  would  en- 
danger this  muscle  more  than  the  latter,  though  if  high  in 
the  fossa  there  may  not  be  much  risk.  The  distended  sac 
is  said  to  be  situated  a  little  above,  and  at  times  even  a 
little  below,  the  point  of  the  ensiform  cartilage ;  hence  the 
trocar  thrust  in  no  lower  than  the  middle  of  this  appendix 
would  not  be  likely  to  endanger  the  diaphragm.  The  chief 
difference,  it  seems  to  me,  resides  in  the  fact  that  in  one 
instance  the  pleural  sac  is  not  likely  to  be  injured,  while 
in  the  other  case  the  trocar  is  pretty  certain  to  perforate 
both  layers  of  the  left  pleura  before  it  enters  the  ^pericardial 
cavity,  for  there  is  not  the  notch^in  the  pleura  that  there 
is  in  the  border  of  the  lung.  In  chronic  pericarditis  the 
pleural  cavity  in  front  of  the  pericardium  will  frequently 
be  obliterated  by  inflammatory  adhesions,  but  in  hydro- 
pericardium  the  pleura  will  be  normal,  and  some  of  the 
fluid  may  leak  into  the  pleural  sac  during  the  operation 
or  after  the  withdrawal  of  the  needle.  This  will  occur 
but  rarely,  and  if  it  does,  the  absorbents  of  the  healthy 
pleura  will  probably  cause  its  disappearance  in  a  short  time, 
and  with  the  aspirator  there  is  no  danger  of  pneumothorax 


QQ  PARACENTESIS   OF  THE   PERICARDIUM. 

occurring.  If  it  were  proposed  to  use  a  drainage-tube,  it 
would  be  more  important  to  be  certain  that  the  pleural 
cavity  was  obliterated  at  the  point  of  operation,  or  else 
to  select  a  point  where  the  pleura  was  not  likely  to  be 
wounded.  Again,  if  we  still  used  the  old  trocar  without 
resorting  to  the  suction  power  of  the  aspirator,  this  ques- 
tion would  assume  more  importance ;  but  aspiration 
empties  the  sac  so  effectually,  and  the  needle  makes  such 
a  comparatively  small  puncture  in  the  pericardium,  that 
leakage  is  not  to  be  expected.  That  leakage  may  occur, 
however,  is  shown  by  Dr.  Paul's  case  (Ro.  60).  If  there 
were  a  coexisting  pleurisy,  so  that  the  pleural  sac  in  front 
of  the  pericardium  was  also  distended  with  serum,  it  might 
be  judicious  to  attempt  opening  the  pericardium  at  the 
inner  situation,  in  order  to  avoid  the  confusion  of  tapping 
two  superimposed  cavities  containing  fluid.  On  this  sub- 
ject the  reader  is  referred  to  the  subsequent  discussion  of 
the  complications  of  pericardial  eifusions. 

In  ordinary  cases,  then,  I  believe  that  the  probability  of 
puncturing  the  pleura  is  not  a  contra-indication  to  tapping 
the  pericardium  over  the  normal  apex  beat.  The  possi- 
bility, however,  of  wounding  the  diaphragm  or  the  liver, 
which  is  prone  to  enlargement  from  venous  engorgement 
in  pericardial  effusion,  coupled  with  the  fact  that  the 
ensiform  cartilage  is  covered  at  its  base  by  the  overlying 
cartilages  of  the  sixth  and  seventh  ribs,  making  it  diffi- 
cult to  determine  its  edge  in  fat  subjects,  renders  para- 
centesis in  the  fossa  between  the  xiphoid  and  seventh 
cartilage  undesirable.  Therefore  I  should  tap  in  the 
former  locality  as  a  rule,  reserving  the  latter  for  special 
cases  where  there  was  some  indication  for  making  an 
exception.  Rotch's  suggestion  to  tap  on  the  right  side  of 
the  sternum,  in  the  fifth  space,  about  four  and  one-half 
or  five  centimetres  from  the  edge  of  the  sternum,  must 


POINT  OF  PUNCTURE.  67 

be  suLjected  to  further  clinical  investigation  before  being 
accepted. 

The  method  of  operating  would  then  be  as  follows : 
The  patient  should  be  as  nearly  recumbent  as  possible,  in 
order  to  allow  the  heart  to  fall  back  from  the  anterior  part 
of  the  pericardial  sac.  The  intercostal  spaces  are  then 
counted  by  recollecting  that  the  first  rib  lies  under  the 
clavicle,  or  that  the  second  rib  joins  the  sternum  at  the 
prominent  joint  between  the  manubrium  and  gladiolus, 
and  bearing  in  mind  that  the  cartilages  towards  the  median 
line  api^roach  each  other  and  ascend  obliquely.  If  the 
cedematous  condition  of  the  cellular  tissue  obscures  the 
situation,  hard  rubbing  of  the  chest  may  render  the  posi- 
tion of  the  ribs  evident.  The  point  is  then  selected  in  the 
fifth  space,  nearer  the  rib  below  than  that  above  in  order  to 
avoid  injuring  the  intercostal  artery,  and  situated  from  two 
to  two  and  a  quarter  inches  (about  five  to  six  centimetres) 
to  the  left  of  the  median  line  of  the  sternum,  which,  on 
account  of  the  irregularity  of  the  bone,  is  more  readily  de- 
termined than  the  border.  It  seems  to  me  that  this  is  far 
enough  from  the  median  line,  and  is  better  than  a  point 
nearer  the  nipple,  because  there  is  a  possibility  of  making 
the  puncture  beyond  the  limits  of  the  pericardium.  In  an 
instance  where  I  made  an  experimental  puncture  on  the  ca- 
daver in  the  fifth  space,  at  a  point  two  and  one-half  inches 
from  the  median  line,  the  instrument  entered  the  pericar- 
dial wall  near  its  apex,  and  passed  between  the  layers  of 
the  membrane  without  entering  the  cavity.  Although  this 
was  in  a  case  where  there  was  no  eft'usion,  it  shows  that 
there  is  such  a  thing  as  going  too  far  to  the  left ;  and  this 
may  especially  occur  in  instances  of  solidification  of  the 
border  of  the  lung  complicating  pericarditis,  for  then  the 
diagnosis  of  the  area  of  dulness,  due  to  the  pericardial 
eftusion,  is  difficult  to  establish.     It  would  be  well  to  vary 


68  PARACENTESIS   OF   THE  PERICARDIUM. 

the  distance  from  the  median  line  of  the  sternum  to  a  slight 
extent  according  to  the  patient's  stature.  In  a  child  two 
inches  would  he  too  far  to  the  left;  hence,  the  relation  of 
the  median  line,  the  apex  beat,  and  the  nipple  must  be 
considered. 

Care  must  be  taken  not  to  strike  the  costal  cartilage  lest 
the  point  of  the  trocar  be  broken,  or  the  needle  plugged 
with  a  disk  cut  from  the  cartilage.  The  caution  is  not  in- 
appropriate, because  this  has  occurred,  and  is  liable  to  take 
place  if  the  surgeon  do  not  recollect  that  the  cartilages  have 
a  different  direction  from  that  of  the  corresponding  ribs, 
whose  axis  is  dowmoards  and  forwards,  but  that  of  the  car- 
tilages upwards  and  forwards.  As  soon  as  the  point  of  the 
puncturing  instrument  is  buried  beneath  the  integument  the 
vacuum  chamber  of  the  aspirator  should  be  attached,  in 
order  that  the  glass  index  in  the  tubing  may  show  by  the 
flow  of  fluid  the  instant  the  pericardium  is  opened.  Unless 
this  is  done,  there  is  risk  of  pushing  the  needle  into  the 
ventricular  wall,  and  it  is  for  this  reason  that  an  ordinary 
trocar  and  canula  should  never  be  used,  even  if  adapted  to 
the  aspirating  pump.  If  the  skin  is  very  thick,  a  prepara- 
tory puncture  ma}^  be  made  with  a  bistoury.  It  is  better 
in  most  instances  to  direct  the  needle  backwards,  but  after 
it  has  entered  the  sac  its  point  may  be  turned  a  little  down- 
wards to  avoid  contact  with  the  heart  as  it  is  thrown  for- 
ward in  systole.  Should  the  dome-shaped  trocar  be  used, 
or  that  with  the  flexible  end  described  by  me,  there  is  no 
danger  on  this  score.  I  should  prefer  to  empty  the  sac 
completely  if  possible,  as  this  avoids  the  possibility  of  leak- 
ing, though  some  may  think  it  better  to  withdraw  only  a 
portion  of  the  effiision  at  first,  and  then  repeat  the  opera- 
tion. As  the  effusion  decreases  and  the  symptoms  of  dysp- 
noea ameliorate,  which  they  generally  do  immediately,  the 
needle  may  be  carefully  retracted  if  there  be  fear  of  lacer- 


POINT  OF  PUNCTURE.  69 

ating  the  heart's  surface.  Finally,  it  is  withdrawn  en- 
tirely. The  capillary  puncture  needs  no  treatment.  If  it 
is  thought  necessary,  a  piece  of  adhesive  plaster  may  be 
placed  over  it.  In  cases  where  it  is  supposed  that  there  is 
floating  lymph  in  the  pericardium,  the  needle  should  be 
larger  than  in  cases  of  simple  dropsy,  when  the  finest 
needle  will  allow  withdrawal  of  the  serum ;  hence  in  in- 
flammatory eifusions  use  an  instrument  of  greater  calibre. 

I  have  thus  discussed  the  method  of  performing  paracen- 
tesis of  the  pericardium ;  it  remains,  then,  to  add  some  re- 
capitulatory words.  Be  sure  not  to  thrust  the  needle  in  too 
deeply,  for  in  emaciated  subjects  the  thoracic  wall  is  very 
thin ;  and  take  care  not  to  pierce  a  cartilage  which  may  lie 
underneath  the  point  you  have  considered  to  be  in  an  inter- 
space. Wlien  a  case  shows  evidence  of  pointing,  as  may 
occur  in  chronic  purulent  pericarditis,  the  tapping  should 
be  done  at  that  point,  without  reference  to  its  situation 
in  one  or  other  of  the  localities  discussed.  So,  also,  if 
the  sounds  of  the  heart  be  very  loud  at  the  point  I  have 
advocated,  and  adhesion  be  inferred,  the  intelligent  opera- 
tor would  select  another  point,  where  weakness  of  sounds 
and  intensity  of  dulness  on  percussion  indicated  that 
the  distance  between  the  pericardium  and  the  heart  was 
greatest. 

It  might  happen  that  there  was  no  flow  of  fluid  after  the 
trocar  was  introduced  through  the  integument,  owing,  per- 
haps, to  the  thickened  pericardium  being  pushed  in  front 
of  the  instrument;  or,  again,  the  flow  might  cease  after 
a  few  moments  on  account  of  the  canula  being  choked  by 
a  plug  of  lymph  or  inspissated  pus.  In  the  former  instance, 
it  is  safer  to  withdraw  the  needle  and  to  ascertain  that 
it  is  not  stopped  by  a  disk  cut  from  a  cartilage,  inadvert- 
ently pierced,  than  to  persist  in  thrusting  it  deeply  inward. 
Another  puncture  can  then  be  made  without  the  risk  of 


3 


70  PARACENTESIS  OF   THE  PERICARDIUM. 

doing  injury  to  the  heart.  In  case  of  obstruction  occur- 
ring from  lymph,  a  wire  may  be  introduced,  or  better  still, 
if  an  aspirating  trocar  like  that  devised  by  me  is  used,  the 
inner  tube  can  be  withdrawn,  and  the  larger  outside  tube 
will  probably  be  of  sufficient  calibre  to  allow  the  flakes  of 
lymph  to  escape. 

It  is  understood  that  a  needle  should  never  be  used 
unless  it  is  perfectly  clean  and  not  blocked  up  by  rust. 
A  case  is  reported*  as  follows  :  M.  Potain  having  a  patient 
with  pericardial  effusion,  introduced  the  aspirating  needle 
in  the  eighth  space,  but  no  fluid  escaped  though  the  in- 
strument had  penetrated  to  the  depth  of  about  three 
centimetres.  The  cardiac  beat  was  felt  against  the  instru- 
ment, and  it  was  withdrawn,  when  it  was  found  to  be 
plugged  with  a  piece  of  false  membrane.  No  subsequent 
trouble  supervened  which  could  be  attributed  to  the 
operation,  but  the  patient  died  six  days  later.  At  the 
post-mortem  examination  it  was  discovered  that  the  peri- 
cardium contained  a  litre  of  sero-purulent  fluid.  A  differ- 
ent result  might  have  occurred  if  the  needle  had  been 
reintroduced. 

In  any  event,  great  care  should  be  exercised  to  prevent 
the  admission  of  air;  if  this  precaution  be  neglected  a 
great  advantage  of  aspiration  is  lost.  I  have  frequently 
seen  the  aspirator  used  in  such  a  bungling  manner  for 
thoracentesis,  that  the  operator  might  as  well  have  em- 
ployed an  ordinary  trocar  at  the  beginning. 

*  Le  Progres  Medical,  1876,  p.  76. 


DANGERS   TO  BE  ENCOUNTERED.  71 


CHAPTER  V. 

DANGERS   TO    BE   ENCOUNTERED. 

There  are  but  two  clangers  of  the  operation  that  need 
discussion  at  this  point,  since  the  question  of  wounding 
the  pleura  and  diaphragm  has  been  sufficiently  considered 
previously.  It  is  necessary  to  lay  before  the  reader  the 
possibility  of  hemorrhage  from  wounding  the  internal 
mammary  artery,  and  to  mention  the  danger  of  striking 
the  ventricle  and  perhaps  entering  the  cavity  of  the  heart. 
The  point  of  puncture  that  I  have  recommended  precludes 
the  possibility  of  injury  to  the  artery,  but  as  circumstances 
may  induce  the  operator  to  select  a  situation  near  the  me- 
dian line,  the  course  of  the  artery  must  be  mentioned. 
After  arising  from  the  subclavian  the  internal  mammary 
runs  downwards,  parallel  with  the  edge  of  the  sternum, 
crossing  the  inner  surface  of  the  costal  cartilages,  until  it 
reaches  the  lower  edge  of  the  sixth  cartilage ;  here,  or  in 
this  neighborhood,  it  bifurcates  into  the  superior  epigas- 
tric, continuing  directly  downwards,  and  the  musculo- 
phrenic, which  runs  downward  and  outward  in  the  sixth 
interspace.  The  trunk  in  the  region  where  it  concerns  us 
is  somewhat  less  than  three  millimetres  in  diameter,  and 
its  two  branches  from  say  one  and  a  half  to  two  millime- 
tres. The  most  important  relation  is  its  distance  from  the 
edge  of  the  sternum,  which  fortunately  is  increased  at  the 
level  of  the  fifth  and  sixth  interspaces  by  the  lessening 
width  of  the  bone  at  its  lower  extremity.  Cruveilhier 
and  Sappey  give  as  the  average  distance  four  to  five  milli- 


72  PARACENTESIS   OF   THE   PERICARDIUM. 

metres,*  Baizeau  says  it  is  ten  to  fifteen  millimetres,  while 
Roger  found  in  children  a  distance  of  only  two  to  three  mil- 
limetres. Some  measurements  of  my  own  in  adults  show 
it  on  the  left  side  to  be  from  one-quarter  to  one-half  an 
inch,  which  would  correspond  to  about  six  to  twelve  milli- 
metres, though  in  the  neighborhood  of  the  iifth  and  sixth 
space  I  have  seen  it  exceed  this.  Hence  there  is  plenty  of 
room  in  adults  to  insert  the  trocar  within  the  line  of  the 
vessel,  if  it  be  kept  close  to  the  edge  of  the  sternum.  In 
fat  patients  there  may  be  difficulty  in  determining  the  edge 
of  the  sternum  with  accuracy,  and  the  artery  may  be  acci- 
dentally wounded.  This  is  the  chief  objection  to  the  opera- 
tion being  performed  at  this  locality.  As  stated  previously, 
the  point  suggested  by  Agnew  seems  improper,  because  I 
found  that  it  was  dangerously  near  the  musculo-phrenic 
branch  of  the  mammary.  If  this  was  found  in  one  in- 
stance only,  it  renders  the  point  more  objectionable  than 
some  others. 

The  proper  method  of  avoiding  the  first  danger,  then,  is 
to  keep  away  from  the  line  of  the  vessel,  and  this  is  done 
by  puncturing  in  the  fifth  space  about  midway  between 
the  sternum  and  the  line  of  the  nipple.  If  in  any  case 
of  operation  by  the  aspirating  needle  the  vessel  were 
wounded,  it  is  probable  that  the  surgeon  would  pass  the 
needle  onward  into  the  pericardium,  and  not  be  aware  of 
the .  division  of  the  artery.  There  would  be  hemorrhage 
into  the  areolar  tissue  of  the  anterior  mediastinum,  but  it 
is  to  my  mind  doubtful  whether  the  amount  would  be  very 
great. 

If  detected,  it  should  be  treated  by  cold  applications  to 
the  chest,  with  ergot  and  astringents  internally.  Since 
the  method  of  preliminary  incision   and   dissection  has 

*  Roger,  op.  cit.,  p.  1271. 


DANGERS   TO   BE  ENCOUNTERED.  73 

been  abandoned,  there  is  little  risk  of  hemorrhage  from 
the  mammary  artery,  if  a  proper  amount  of  care  be  taken 
in  selecting  the  point  of  puncture. 

An  accident  of  much  more  importance  is  injury  done 
to  the  heart,  which  may  occur  from  thrusting  the  trocar 
into  the  substance,  or  even  into  the  cavity  of  the  heart. 
A  mere  abrasion  or  scratch  of  the  surface  of  the  organ  is 
of  little  moment,  for  its  only  tendency  would  be  to  cause 
a  slight  local  pericarditis,  which  would  not  aggravate  the 
existing  condition.  It  may  happen,  however,  that  the 
operator's  instrument  pass  into  the  tissue  of  the  ventricle 
before  he  is  aware  of  it,  and  that  he  push  it  onward,  in  his 
search  for  fluid,  until  pure  blood  escapes  from  the  cardiac 
cavity.  That  this  is  not  an  impossible  accident  is  shown 
by  Roger,  who  believes  that  his  case,  numbered  29  in 
the  table,  may  have  shown  blood  at  first,  because  the 
ventricle  was  punctured.  The  same  question  also  arises 
in  considering  the  case  of  Baizeau,  where  clots  were 
found  in  the  pericardial  cavity  at  the  autopsy.  It  must 
be  admitted,  however,  that  no  wound  of  the  heart  was 
visible  in  either  instance  when  the  autopsy  was  made, 
though  in  the  latter  case  the  patient  died  a  couple  of 
hours  after  the  operation. 

Roger's  third  case  is  related  by  him  as  a  genuine  in- 
stance of  wound  of  the  heart.  I-  shall,  therefore,  give  it 
more  in  detail  than  in  the  tabulated  account.  The  boy 
was  five  years  old,  and  sufifered  from  pericarditis.  AYhen 
the  aspirator  was  introduced  there  was  at  first  no  fluid 
found;  then  there  escaped  blood  mixed  with  sejosity; 
then  pure  blood  resembling  venous  blood,  and  this  flowed 
in  a  steady  stream  without  pulsation.  Two  hundred 
grammes  were  thus  evacuated  when  the  child  became  pale, 
and  the  needle  was  withdrawn.  Subsequently,  it  was  de.- 
termined  that  there  was  less  prominence  of  the  chest  and 

6 


74  PARACENTESIS  OF  THE  PERICARDIUM. 

less  dulness,  and  the  cardiac  sounds  were  more  superficial; 
but  the  child  was  pale,  was  sweating,  and  had  an  im- 
perceptible pulse.  Improvement  and  cure  followed,  and 
the  pericardial  symptoms  did  not  return,  though  the  case 
was  under  observation  for  three  months.  The  antecedent 
organic  trouble  of  the  heart  itself,  however,  progressed, 
and  death  took  place  about  five  months  after  the  tapping. 
The  autopsy  showed  dilatation  of  the  cavities  of  the  heart 
with  mitral  insufficiency,  and  general  pericardial  adhesion. 
Roger  himself  says  that  the  blood  came  directly  from  the 
right  ventricle. 

In  this  connection  a  most  remarkable  case,  reported 
to  the  Clinical  Society  of  London,*  may  be  mentioned. 
It  is  the  same  case  related  in  a  preceding  chapter.  A 
woman,  aged  twenty-seven  years,  had  pleuro-pneumonia 
and  signs  of  large  pericardial  effusion ;  as  she  Avas  almost 
moribund  a  trocar  was  introduced  by  Mr.  Hulke  through 
the  fourth  interspace,  but,  to  the  dismay  of  the  surgeon, 
dark,  venous  blood  escaped.  The  instrument  was  im- 
mediately withdrawn,  but  the  patient,  instead  of  showing 
unfavorable  symptoms,  seemed  to  be  relieved  of  the  dis- 
tress and  dyspnoea.  She  died  four  weeks  later  of  a  com- 
plication of  diseases,  when  the  autopsy  showed  dilatation 
and  valvular  disease  of  the  heart,  with  the  pericardium 
universally  adherent,  but  no  effusion.  These  two  in- 
stances prove  that  a  wound  of  the  heart  is  not  impossible 
even  in  capable  hands,  and  also  tend  to  show  us  that 
there  is  not  as  much  danger  of  fatal  syncope  occurring 
under  these  circumstances  as  we  should  suppose.  In  fact, 
in  the  latter  case,  although  the  right  ventricle  was  tapped 
and  one  drachm  of  blood  withdrawn,  the  patient  ex- 
hibited no  shock  or  distress ;  but  the  abstraction  of  blood 

*  Transactions  Clinical  Society,  viii.  p.  169. 


DANGERS   TO   BE  ENCOUNTERED.  75 

seemed  to  relieve  the  distended  heart  much  better  than 
phlebotomy  would  have  done,  as  was  evinced  by  the 
diminution  of  threatening  symptoms  and  the  decrease  of 
the  area  of  dulness. 

Though  no  great  fatality  seems  to  attend  this  accident, 
it  is  one  to  be  avoided  with  scrupulous  care ;  hence  the 
propriety  of  selecting  a  low  point  of  puncture  near  the  apex 
of  the  heart,  rather  than  towards  the  base,  where  the  space 
between  heart  and  wall  of  thorax  is  less.  Another  ob- 
jection to  a  high  puncture  is  the  much  graver  prognosis 
attending  wounds  of  the  thin-walled  auricle.  Dr.  Steiner 
in  his  experiments  with  electro-puncture  found  that  needles 
could  be  quite  safely  introduced  into  either  ventricle,  pro- 
vided they  were  at  once  withdrawn;*  but  it  is  not  so  safe 
to  puncture  the  auricles.  Other  observers,  such  as  Cloquet, 
Bouchut,  Legros,  and  Onimus,  have  noticed  the  apparent 
innocuousness  of  wounds  of  the  heart  made  by  capillary 
trocars.  A  case  bearing  upon  this  point  is  recorded,  in 
which  a  needle  had  accidentally  entered  the  chest  and 
penetrated  the  heart  to  some  depth.  With  the  exception 
of  pain  no  symptoms  of  note  were  observed,  and  the  for- 
eign body  was  shortly  afterwards  removed  without  causing 
the  slightest  local  or  constitutional  disturbance.  Again, 
a  needle  has  been  found  firmly  fixed  across  the  ventricular 
septum,  which  had  evidently  been  there  a  long  time,  for 
it  was  coated  with  lymph,  and  death  had  been  the  result 
of  other  causes. f 

In  this  connection  I  must  mention  an  instance  where 
death  occurred  apparently  from  the  operation  of  paracen- 
tesis, though  the  aspirating  needle  did  not  wound  the  heart 


*  Med.  Times  and  Gazette,  May,  1873,  p.  492;   from  Langenbeck's 
Archiv  fiir  Klin.  Chirurgie. 

f  Med.  Times  and  Gazette,  May,  1873,  p.  491. 


76  PARACENTESIS   OF  THE  PERICARDIUM. 

itself,  and  failed  to  reach  the  effusion.  A  man  was  sup- 
posed to  have  effusion  in  the  pericardium,  and  aspiration 
was  attempted  in  the  third  interspace,  but  no  fluid  escaped, 
and  he  died  almost  immediately.  The  autopsy  revealed 
the  fact  that  the  instrument  had  pierced  not  the  heart  wall 
as  might  be  expected,  but  had  penetrated  the  thickened 
pericardium  at  a  point  where  it  was  adherent  to  the  heart. 
The  pericardium  was  adherent  to  almost  the  whole  of  the 
left  heart,  while  at  the  right  there  was  a  cavity  containing 
twelve  hundred  grammes  of  fluid.  There  was  also  valvular 
disease.*  How  to  explain  this  sudden  death  from  shock 
I  do  not  know.  The  operation  was  done  higher  up  than 
usual,  and  death  may  have  been  due  to  some  interference 
with  cardiac  action  resulting  from  injury  to  the  auricle 
with  its  adhering  pericardium,  that  had  assumed  the  func- 
tions of  the  auricular  wall.  It  is  possible  that  the  man, 
enfeebled  by  valvular  disease  and  the  pressure  from  the 
large  effusion,  was  unable  to  withstand  the  mental  and 
physical  shock  produced  by  the  operation.  I  have  omitted 
this  case  from  the  table  of  cases  of  paracentesis  pericardii 
because  the  pericardial  cavity  was  not  opened,  and  there- 
fore it  could  not  be  classed  among  them.  The  importance 
of  the  case  requires  its  insertion  here  in  order  that  I  may 
present  a  scientific  and  non-partisan  view  of  the  subject 
in  all  its  bearings. 

The  experiments  of  Steiner  and  others  have  been  quoted, 
not  to  encourage  careless  employment  of  surgical  means 
in  treating  pericardial  eftusions,  but  to  let  it  be  known  that 
we  should  throw  aside  the  foolish  prejudice  that  makes  us 
shun  operative  interference  in  pericarditis  because  of  the 
supposed  vulnerability  of  the  heart.     If  the  cases  of  peri- 

*  Bull.  Gen.  de  Therap.,  1878,  tome  xciv.  p.  428;  from  Union  Med. 
and  Gaz.  des  Hop.,  1878,  p.  310. 


OBJECTIONS   TO   THE  OPERATION.  77 

cardial  effusion  be  properly  selected,  and  diligent  care  be 
exercised  in  the  performance  of  the  operation,  the  risk  of 
striking  the  heart  is  very  slight.  If  the  heart  should  be 
punctured  through  some  unforeseen  contingency,  such  as 
an  unsuspected  adhesion,  it  will  probably,  if  we  are  to 
judge  by  the  cases  quoted,  add  little  to  the  gravity  of  the 
case,  which,  to  say  the  least,  is  already  very  grave  when 
the  operation  is  suggested.  Hence  I  conclude  that  the 
fear  of  wounding  the  central  organ  of  circulation  should 
not  deter  the  surgeon  from  tapping  the  pericardium,  if  the 
diagnostic  signs  warrant  the  attempt.  He  must  be  careful 
that  no  disk  of  cartilage  or  shred  of  membrane  occludes 
his  needle,  and  then  he  can  push  it  onward  until  the  index 
shows  the  fluid  escaping.  In  thick,  oedematous,  or  fatty 
walls  it  may  be  necessary  to  go  to  a  depth  of  four  or  five 
centimetres  before  reaching  the  fluid;  hence  it  is  abso- 
lutely essential  that  the  needle's  patulency  be  assured. 

OBJECTIONS    TO    THE    OPERATION. 

I  deem  it  proper  to  devote  some  time  to  considering  the 
objections  that  have  been  advanced  against  the  adoption  of 
paracentesis  pericardii  as  a  justifiable  procedure.  In  the 
first  place,  it  has  been  said  almost  with  a  sneer  that  the 
operation  is  merely  palliative.  Kow,  even  if  I  were 
willing  to  admit  this,  which  ^  am  not,  I  should  still 
insist  upon  the  performance  of  paracentesis  of  the  pericar- 
dium in  proper  cases.  In  many  incurable  afi'ections  we 
must  labor  with  all  our  might  to  palliate  the  sufferings  of 
the  patient.  If  it  were  right  to  do  so,  the  surgeon's  feel- 
ings of  humanity  might  prompt  him  to  hasten  dissolution 
when  he  sees  and  hears  the  agony  of  a  man  with  hydro- 
phobia; but  no,  he  must  palliate.  He  can  destroy  a  brute 
to  relieve  prolonged  suffering,  but  he  must  sustain  the 
life  of  a  human  being.     Hence  palliative  measures  are 


78  PARACENTESIS  OF  THE  PERICARDIUM. 

urgently  demanded  in  every  department  of  medicine.  If 
a  few  days  can  be  added  to  a  life  by  tapping  the  pericar- 
dium, it  should  be  done;  aye,  and  done  quickly.  Allbutt, 
when  discussing  the  objection  of  one  who  says,  "In  the 
majority  of  cases  I  believe  the  result  has  been  unfavor- 
able,"* argues,  very  properly,  that  "unfavorable"  must 
mean  that  the  operation  itself  caused  death,  hastened  the 
fatal  issue,  or  augmented  the  suifering  of  the  patient  while 
doing  no  good  whatsoever.f  An  examination  of  the  ac- 
companying table  shows  that  these  effects  are  not  charge- 
able to  the  operation,  but  that  it,  as  a  rule,  relieves  suffer- 
ing at  once  and  prolongs  life. 

This  feeling  of  hostility  to  the  operation  has  of  late  years 
been  considerably  modified,  and  I  doubt  whether  Billroth 
would  now  say  that  the  operation  seemed  almost  like  pros- 
titution of  surgical  skill,  or  speak  of  its  resemblance  to  a 
surgical  frivolity. | 

Jaccoud  speaks  of  the  operation  as  legitimate  at  times, 
but  says  that,  after  the  performance  of  paracentesis  of  the 
pericardium,  the  liquid  is  reproduced  with  great  facility 
on  account  of  the  diminution  of  extra-vascular  pressure. § 
This  statement  I  am  unwilling  to  accept  as  a  clinical  fact, 
and,  even  if  true,  I  should  not  feel  that  it  carried  much 
weight  as  an  objection  to  the  operation. 

As  an  answer  to  those  who  disparage  the  operation  be- 
cause of  its  merely  palliative  character  in  many  instances, 
I  will  state  that  in  the  table  of  60  cases  of  operation  there 
are  recorded  36  deaths.  Of  these  fatal  cases,  23  patients 
are  known  to  have  survived  the  operation  for  one  da}^  or 

*  British  Medical  .Journal,  July  2,  1870. 
t  Ibid.,  July  9,  1870,  p.  32. 

X  Handbuch  der  Allgemein.  und  Speciellen  Chirurgie,  III.  Bd.,  II. 
Abt.,  I.  Lf.,  163  S. 

I  Pathologie  Interne,  i.  646. 


OBJECTIONS   TO    THE   OPERATION.  79 

more,  9  are  known  to  have  lived  less  than  a  clay  after  the 
operation,  and  in  4  instances  the  time  of  survival  is  not 
given.  The  average  time  of  survival  of  those  who  are 
known  to  have  lived  one  day  or  more  is  over  27  days. 
The  greatest  length  of  time  was  160  days.  If  it  be  recol- 
lected that  most  cases  are  not  considered  proper  for  opera- 
tion until  the  patient  is  almost  moribund,  this  is  certainly 
a  good  showing.  Four  weeks  is  a  long  time  to  add  to  a 
man's  life,  especially  when  it  can  be  done  by  an  operation 
that  causes  so  little  pain. 

The  probability  of  adhesion  of  the  two  layers  of  the 
pericardium  occurring  after  tapping  has  been  held  as  a 
contra-indication,  because  adhesions  may  induce,  it  is  said, 
valvular  disease  or  pathological  changes  in  the  cavities  of 
the  heart.  If  such  is  the  ultimate  etfect  of  adhesion,  it  is 
better  than  the  existing  condition  of  pericardial  effusion, 
which  gives  rise  to  m^^ocarditis  and  pathological  sequences 
of  more  immediate  danger.  That  general  adhesion  does 
take  place  in  inflammatory  effusions  is  probable.  Kyber 
found  that  it  had  occurred  in  three  of  his  cases  of  recovery 
after  paracentesis,  where  autopsies  were  obtained  long 
afterwards;*  and  Pepper's  case  (No.  57)  showed  the  same 
condition  when  the  post-mortem  examination  was  made 
fifteen  months  after  the  operation.  It  would  seem  that  a 
radical  cure  is  to  be  looked  for  i^i  the  occurrence  of  union 
of  the  two  surfaces,  and  if  this  be  true,  the  objection  to  the 
operation  on  the  score  of  pericardial  adhesion  falls.  After 
all,  the  degree  of  agency  exercised  by  adhesions  in  the 
production  of  other  cardiac  lesions  is  a  disputed  matter, 
as  will  be  seen  by  careful  perusal  of  the  works  on  heart 
affections.  Are  we  to  reject  an  operation  which  prevents 
imminent  death  because  we  fear  it  will  lead  to  a  condition 

*  Monthly  Ketrospect  of  Medical  Science,  Edinburgh,  March,  1848. 


80  PARACENTESIS   OF  THE   PERICARDIUM. 

tliat  lias  a  doubtful  agency  in  producing  otlier  less  fatal 
ailments  ? 

An  objection  of  more  force  than  either  of  those  thus  far 
reviewed  is  the  assertion  that  the  fluid  accumulates  with 
greater  rapidity  after  tapping  than  previously,  and  that  it 
has  a  tendency  to  become  purulent.  We  have  not  sufli- 
cient  data  to  answer  this  point,  but  I  do  not  see  that  the 
objection  is  of  any  more  value  than  against  aspiration  in 
pleuritis,  where,  if  the  fluid  reaccumulate,  the  needle  is 
introduced  again  and  again,  and  cure  finally  effected ;  and 
if  the  pleural  efirision  become  purulent,  it  is  evacuated 
either  by  repeated  tapping  or  by  continuous  drainage. 
The  proper  method  of  obviating  suppuration  is  to  avoid 
the  entrance  of  air  into  the  cavity  during  the  operation. 
The  line  of  treatment  which  meets  this  indication,  and 
the  course  to  pursue  after  pus  has  formed,  will  be  found 
in  the  chapter  which  treats  of  the  methods  of  operating. 
In  Frerich's  ward,  where  thoracentesis  is  frequently  per- 
formed, no  serous  efiusion,  it  is  stated,  becomes  purulent 
if  the  instrument  be  disinfected  and  the  air  excluded  from 
the  pleural  cavity.*  This  would  probably  correspond  with 
general  experience.  Is  there  any  difierence  in  this  regard 
between  pleura  and  pericardium  ? 

There  can  be  no  valid  objection  urged  against  a  second 
operation  if  the  first  has  been  deemed  justifiable.  A 
study  of  the  table  of  operations  will  furnish  information 
concerning  this  matter.  The  cases  of  Scliuh  and  one  or 
two  others  must  be  omitted,  since  in  them  the  first  tapping 
failed  to  give  exit  to  the  fluid,  and  a  second  operation  was 
immediately  performed. 

It  is  stated  that  the  operation  was  done  more  than  once, 
as  follows : 

*  Medical  and  Surgical  Eeporter,  September  30,  1876,  p.  274. 


OBJECTIONS   TO   THE   OPERATION.  81 

There  were  tapped  twice  .         .         .         .         .         .11  patients. 

"      was         "       three  times  ....       1  patient. 

"        "  "       six  times 1         " 

"        "  "       eight  times  ....       1         " 

There  was  a  repetition  of  the  operation  therefore  in     14  patients. 

The  patient  wlio  was  tapped  six  times  (I^o.  43)  lived 
thirty-eight  days  after  the  first  operation,  or  ten  days  after 
the  sixtli,  and  finally  died,  having  peritonitis  in  addition 
to  pericarditis,  Bouchut's  patient  (IS'o.  48)  was  tapped 
eight  times,  and  lived  thirty-four  days  after  the  primary 
operation.  Death  occurred  three  days  after  the  final  tap- 
ping, when  the  heart  itself  was  punctured.  The  shortest 
interval  between  the  original  operation  and  the  second 
was  rather  less  than  one  day ;  in  other  cases  the  period  is 
shown  by  the  full  histories  to  have  been  as  long  as  fourteen, 
fifteen,  and  seventeen  days. 

Let  us  return,  however,  to  the  questions :  Does  paracen- 
tesis itself  cause  rapid  reaccumulation  ?  and,  if  so.  Is  the 
second  operation  more  dangerous  than  the  first  ?  In  the 
first  place,  there  are  twenty-three  cases  reported  ^where 
recovery  followed  paracentesis  without  a  second  operation 
being  necessitated,  and  in  the  fourteen  instances  where  it 
was  required  there  was  additional  disease  in  every  case. 
Secondly,  of  the  fourteen  cases  of  repeated  tapping  thir- 
teen died ;  but  in  all  of  them  there  was  either  disease  of 
the  heart  or  lungs,  as  in  nine,  scurvy  or  abdominal  disease, 
as  in  three,  or  brain  disease,  as  in  one ;  and,  indeed,  the  one 
patient  who  recovered  after  double  tapping  had  phthisis 
(Eo.  19).  These  statistics  seem  to  show  pretty  conclu- 
sively that  repeated  tapping  is  not  demanded  as  a  sequel 
of  first  paracenteses,  but  is  required  because  the  patient's 
condition  causes  a  spontaneous  reaccumulation,  which 
would  occur  if  the  efiiision  was  suddenly  removed  by  any 
other  method  that  did  not  at  the  same  time  improve  his 


82  PARACENTESIS   OF  THE  PERICARDIUM. 

diathesis.  They  also  militate  against  tlie  idea  that  there 
is  decided  risk  in  tapping  more  than  once,  for,  though  it 
is  not  proved  that  these  patients  died  of  the  accompanying 
disease,  yet  it  is  shown  that  the  fatal  cases,  where  repeated 
paracentesis  was  performed,  were  decidedly  unfavorahle. 
Therefore  the  evidence  is  of  value,  though  it  be  negative. 
More  positive  evidence  is  the  fact  that,  in  nine  of  the  thirteen 
fatal  cases  of  repeated  tapping,  the  time  of  survival  after  the 
second  operation  was  one  day  or  more,  while  in  some  cases 
the  patient  survived  many  days  after  the  second  operation. 
In  the  four  remaining  instances  death  occurred  in  less  than 
a  day,  or  the  time  is  unknown.  There  is  no  proof  in  this 
that  a  second  operation  is  to  be  dreaded  any  more  than  the 
primary  one,  except  in  so  far  as  it  suggests  the  probability 
of  some  affection  complicating  the  pericardial  effusion. 

TREATMENT    OF    COMPLICATIONS. 

Having  carefully  taken  up  in  detail  the  steps  to  be  pur- 
sued in  treating  pericardial  effusions,  I  shall  occupy  a  few 
pages  with  some  consideration  of  the  management  of  com- 
plications that  may  exist  as  causes  or  results  of  the  effusion 
in  the  pericardial  cavity.  Pleuritis  with  effusion  is  a 
not  uncommon  accompaniment  of  pericarditis,  as  has  been 
shown  when  discussing  the  aetiology  of  inflammation  of 
the  heart's  investment ;  so,  also,  pneumonia  is  frequently 
found  in  a  similar  relationship.  These  affections  must  be 
treated  on  the  general  principles  that  guide  the  physician 
in  managing  cases  unaccompanied  by  pericardial  disease. 
The  difficulty  of  diagnosis  that  may  arise  between  left 
pleuritic  effusion,  especially  if  encysted,  and  effusion  in 
the  pericardium  has  been  mentioned.  Occasionally  it  is 
hard  to  calculate  the  degree  of  causation  exerted  by  these 
two  effusions  in  producing  the  symptomatic  manifesta- 
tions observed.     There  exist   certain  symptoms,  such  as 


TREATMENT  OF  COMPLICATIONS.  83 

cyanosis,  dyspnoea,  feeble  circulation,  etc.;  are  they  due 
to  the  serum  in  the  pleura  or  to  that  in  the  pericardium  ? 
Wlien  the  pleural  eiFusion  is  relatively  much  greater  in 
amount,  the  question  can  be  decided ;  but  cases  arise  in 
which  it  is  almost  impossible  to  say  which  is  the  more 
active  agent.  If  there  be  any  doubt,  it  is  proper  to  per- 
form thoracentesis  first,  and  then  await  results ;  if  relief 
does  not  follow,  the  pericardium  is  to  be  punctured  sub- 
sequently. There  is  no  objection  to  doing  both  opera- 
tions at  one  time,  if  they  are  indicated  by  the  condition 
of  the  patient. 

The  treatment  of  renal  symptoms  must  be  governed  by 
the  general  indications  in  much  the  same  manner ;  but  I 
wish  to  enforce  attention  to  the  fact  that  albuminuria  and 
urfiemic  convulsions  may  be  due  to  the  pressure  from  the 
pericardial  eifusion,  and  that  the  surgeon  should  not  hesi- 
tate to  tap  because  he  finds  evidences  of  kidney  trouble. 
Often  there  is  hydro-pericardium  as  a  part  of  a  general 
dropsical  condition,  induced  by  renal  disease,  but  the  re- 
verse may  be  the  proper  relationship.  In  other  words, 
what  is  cause  in  one  instance  may  be  effect  in  another. 
The  nephritic  congestion  or  inflammation  is  to  be  treated 
by  diuretics,  such  as  digitalis,  scoparius,  juniper,  and  by 
derivatives,  such  as  jaborandi;  but  it  is  useless  to  mention 
measures  or  methods  of  medication,  since  this  belongs  to 
general  clinicar  medicine,  and  not  to  the  subject  of  our 
present  volume. 

There  have  been  a  few  cases  recorded  where  a  pericar- 
dial fistula  has  been  established  either  by  a  spontaneous 
or  operative  evacuation  of  the  eftusion.  Some  cases  so 
called  have  doubtless  been  pleural  fistules,  or  superficial 
sinuses  due  to  a  subtegumentary  abscess.  If  they  are 
truly  pericardial,  I  advise  dilatation  of  the  orifice  with 
compressed  sponge,  and  washing  of  the  pericardial  cavity 


84  PARACENTESIS   OF   THE   PERICARDIUM. 

with  astringent  and  disinfectant  solutions.  It  may  be  that 
the  layers  of  pericardium  are  adherent,  and  that  the  sinus 
opens  into  a  small  suppurating  pocket  between  the  visceral 
and  parietal  membrane ;  or  this  pocket  may  be  external  to 
the  pericardium  entirely,  and  be  formed  in  the  midst  of 
some  new  tissue  occupying  the  mediastinum.  It  is,  of 
course,  useless  to  expect  closure  of  the  external  opening 
if  there  is  a  continual  secretion  of  pus  within,  and  it 
may  be  necessary  to  lay  open  such  cavities.  Sinuses 
that  are  superficial  demand  similar  treatment.  They 
should  be  laid  open  with  the  bistoury,  and  forced  to  gran- 
ulate from  the  bottom.  It  is  possible  that  such  patho- 
logical conditions  may  depend  for  their  existence  upon  a 
diseased  rib  or  cartilage;  if  such  be  the  fact,  resection,  or 
removal  of  the  diseased  tissue  with  the  burr  or  chisel,  is 
to  be  considered. 


CHAPTER  VI. 

TABLE   OF   CASES. 


After  an  extended  search  through  very  many  volumes 
of  text-books,  monographs,  and  journals,  and  after  a  good 
deal  of  correspondence,  I  have  collected  sixty  cases  of  para- 
centesis of  the  pericardium,  and  have  embodied  them  in 
the  followino;  table.  Some  cases  that  I  have  found  men- 
tioned,  or  have  heard  of,  I  have  rejected,  because  I  could 
not  get  any  definite  information  of  them,  or  because  I  be- 
lieved them  to  be  of  doubtful  authenticity.  I  have  person- 
ally examined  many  files  of  German,  French,  Italian,  and 
Spanish  journals  in  order  to  get  trace  of  the  cases  operated 


TABLE   OF  CASES.  85 

upon  tliroughout  the  continent  of  Europe;  and  the  fact 
that  I  have  again  and  again  met  references  to  cases  al- 
ready tabulated,  seems  to  me  conclusive  evidence  that  my 
search  was  pursued  with  a  considerable  degree  of  thor- 
oughness, and  that  I  have  missed  very  few  recorded  oper- 
ations. It  may  be,  and  probably  is,  a  fact,  that  I  have 
failed  to  collect  all ;  but  a  prolonged  study  of  indexes  and 
a  watchful  eye  on  current  literature  during  a  number  of 
years  have  probably  given  me  an  opportunity  of  finding 
nearly  all  the  published  operations.  It  may  be  observed 
that  some  of  the  cases,  that  appeared  in  a  table  published 
by  me  a  few  years  ago,  are  changed  in  certain  respects 
in  the  present  work.  This  is  due  to  my  having  gained 
more  reliable  information  respecting  the  points  of  inter- 
est. In  this  table  I  have  omitted  Bowditch's  case,  which 
was  placed  in  the  otlier  on  the  authority  of  Trousseau. 
Dr.  Pepper  states  that  Bowditch  says  he  never  performed 
the  operation.  "When  compiling  the  first  series  of  cases  I 
wrote  to  Dr.  Bowditch,  of  Boston,  but  never  obtained  any 
answer  from  him,  owing  doubtless  to  my  letter  being  mis- 
laid, for  I  know  that  he  was  away  at  the  time. 

Some  of  the  cases  have  two  names  attached.  This  is 
due  to  the  fact  that  occasionally  a  case  is  reported  in 
different  journals  under  a  difi'erent  name,  owing  to  the 
journal  which  makes  the  abstract  or  excerpt  getting  the 
names  of  the  operator  and  attending  physician  confused. 
In  this  way  I  have  several  times  met  the  same  case  under 
a  different  heading,  and  have  thought  I  had  found  a  new 
instance  of  the  operation,  until  comparison  of  the  dates, 
ages,  results,  etc.,  has  proved  that  I  was  in  error.  To 
avoid  misapprehension  I  have  added  the  second  name  in 
parenthesis. 


86 


PARACENTESIS   OF   THE   PERICARDIUM. 


H 

r. 

a 
« 
Id 

Eh 

a 
P5 

Diet,  des  Sciences  Me- 
dicales,  Paris,  1819, 
xl.  371. 

Do. 

Do. 

GUnther,       Blutigen 

Operationen,  iv.  3, 

British    and  Foreign 
Medical       Review, 
July,  1841. 
Do. 

-a  a 

Monthly     Retrospect 
of  Medical  Sciences, 
Edinburgh,  March, 
1848,  i.  35. 

Archives  Gene  rales  de 
Medecine,    Novem- 
ber, 1854. 

GUnther,       Blutigen 
Operationen,  iv.   3, 
102. 

Do.,  and  also  Monthly 
Retrospect  of  Medi- 
cal Sciences,  March, 
1848,  i.  p.  35. 
Do. 
Do. 

i 

.1 

1 

Scurvj'. 
Scurvy. 

a 

Scurvy. 

Phthisis. 
Scurvy? 
Scurvy. 

Scurvy. 

H 

o 
u 
o 

1 
w 

Hemorrhagic  scorbutic  pericar- 
ditis. Drew  off  Oiijss.  Quite 
well  five  months  later. 

Scorbutic  pericarditis. 

Tapped    first    in    third   inter- 
space.   Case  was  one  of  en- 
cephaloid  disease  of  thoracic 

viscera. 
Scorbutic  pericarditis. 

Tapped  twice.  1500  grammes 
and  400  grammes.  Drainage- 
tube  left  in  six  hours. 

Hemorrhagic  effusion.  Re- 
moved 5  lbs.  Recovered  in 
six  weeks. 

Scorbutic  pericarditis.  Was 
living  one  and  a  half  years 
later. 

Scorbutic  pericarditis. 

Tapped  twice,  with  interval  of 
17  days.  Scorbutic  pericar- 
ditis. 

2'3 

3" 

■a 

3  ~S 

69  days. 
17  days. 

•q;^3a 

iHcw 

iH 

- 

r-                                                            tH 

•iCjSAoos]! 

IH               IH 

lH 

r-(                                     r-l              iH                   rH 

Bistoury    and    scis- 
sors.    5th    inter- 
space. 

Do. 

Do. 

Not  stated. 

Trocar.     5th  inter- 
space. 

Do.? 

p 
E-i 

Trocar.*    4th  inter- 
space. 

Trocar.     5th   inter- 
space. 

Trocar. 

Trocar.     4th  inter- 
space. 

Do. 
Do. 

•aSy  pnu  X9g 

M.  35 

M.  37 
M.  45 
P.   14 

g     s 

1^ 

oa 

8          a       g       a          g'a 

1 
Q 

Before 
1819 

Do. 
Do. 

1827 

o          en 

1 

O                     rH               (M               CO                     lOUi 

X         »      «      s        »« 

O 

1,  Romero. 

2,  Romero. 

3,  Romero. 

4,  Jowett. 

5,  Karawagen. 
G,  Karawagen. 

-a 
a 

m 

8,  Kyber. 

9,  Heger. 

10,  Schonberg. 

11,  Kyber. 

12,  Kyber. 

13,  Kyber. 

TABLE   OF  CASES. 


87 


H 

a 

H 

GUnther,  and  also 
Monthly  Retrospect 
of  Medical  Sciences, 
March,  1848,  i.  p.  35. 

H.  II.  Smith's  Sur- 
gery, ii.  358. 

Bull,  de  TAcad^mie 
de  Medecine,  1875, 
p.  12CG. 

Trousseau,      Clinical 
Medicine,  iii.  370. 

Archives  Gfinerales  de 
Medecine,    Novem- 
ber, 1854. 
Trousseau,       Clinical 
Medicine,  iii.  380. 

Id.,  iii.  391. 
Id.,  iii.  391. 
Id.,  iii.  383. 
Ilalf-Yeaily   Abstract 
of  the  Medical  Sci- 
ences, XXV.  p.  95. 

Trousseau,      Clinical 
Medicine,  iii.  304. 

GUnther,       Blutigen 
Operationen,  iv.  3, 
102. 

■3. 

a 
0 

Scurvy. 

Phthisis. 

Died  of 
pneu- 
monia. 

Phthisis. 

Valvular 
disease. 

Pleurisy 

ami 

phthisis. 
Scurvy  1 

OS 

•< 
s 

Scorbutic  pericarditis. 

Removed  f.  oz.  v.  Left  hospital 
in  a  few  weeks. 

C15  grammes.  18  months  after 
was  woiking  as  a  sailor. 
Roger  says  this  was  a  com- 
plete cure. 

Removed  400  grammes. 
Tapped  jdeura  ahso  for  ef- 
fusion. Under  notice  three 
months. 

Removed  250  gi-ammes. 
Tapped  previously  in  7th  in- 
terspace ;  no  fluid  obtained. 

Tapped  twice.  F.  oz.  xxviij 
and  f.  oz.  xlix.  Injected 
iodine  and  iodide  of  potas- 
sium after  each  tapping. 

Tapped  twice.  First,  500 
grammes ;  second,  three  days 
later, 400  grammes.  Tapped 
abdomen  for  ascites. 

Removed  f.  oz.  iij  ?  Tapped 
pleura  accidentally  at  same 
time. 

Hemorrhagic  pericarditis. 

• 
26  days. 

21  days. 

5  days. 
C  hours. 

■mvaa 

^r.                   r.              ^ 

•IjSAODaa                     rH                     rH         fH                     rt                                        r-(                     r-trH 

•s 

e  g 
1 

Trocar.     4th   inter- 
space. 

Incision  and  trocar. 
Cth  interspace. 

Trocar.  4th  inter- 
space. 

Incision  and  trocar. 
5th  interspace. 

Trocar.     Cth  inter- 
space*. 

Incision  and  trocar. 
5th  interspace. 

Do. 

Not  stated. 
Not  stated. 
Trocar.     5th   inter- 
space. 

Incision. 

•93v  puB  xas 

M. 

F.   35 
M. 

M.  IG 

F.   22 
M.  23 

M.  23 

M.  27 

Date. 

184- 

1852 
1849 

1854 

1854 
1855 

1855 

1856 
1857 

0 

H 

-« 

s 

H 

a, 
0 

14,  Kyber. 

15,  J.  C.  Warren. 
10,  Champouillon. 

17,  Jobert. 

18,  Behier. 

19,  Aran. 

20,  Aran. 

21,  Aran. 

22,  Skoda. 

23,  Vernay. 

24,  Trousseau- 

25,  Wilezkowski. 

88 


PARACENTESIS  OF  THE  PERICARDIUM. 


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■   z 

a 

K 

H 

U 

i 

O  00 

-■^ 

.Ho 

P. 

M 

go      -OS        -  §  oT 

Lancet,  June  12, 1869. 

Bull,    de    I'Acadeniie 
de    Medicine,  1875, 
p.  1273;  Gaz.  Hebd. 
de  Medeciue  et  de 
Chirurg.,  1868. 

P.3 
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TABLE  OF  CASES. 


89 


« 
U 

Bull.  G6n.  de  Therap., 
1871,  tome  Ixxx.  p. 
125.  Dieulafoy  on 
Pneumatic  Aspira- 
tion, London,  1873, 
p.  235. 

Bull,  de  I'Academie  de 
Medecine  (1875),  t. 
xl.  p.  1216  ;  also,  id., 
t.  xxxvii.  p.  658. 

Bull,  de  I'Academie  do 
Medecine,    1875,  p. 
1276. 

Dieulafoy     on    Pneu- 
matic     Aspiration, 
Loudon,  1873,  p.  241. 

Complication. 

Left  pleuri- 
tis. 

Dilatation 
and  val- 
vular dis- 
ease  of 
heart. 

Left  pleuri- 
tis. 

Remarks. 

800  grammes  soro-pus.  Passed 
from  notice  after  GO  days,  but 
had  symptoms  of  chronic 
lung  disease.  On  withdrawal 
of  needle  found  piece  of  car- 
tilage in  the  end. 

Intended  to  tap  left  pleura,  as  di- 
agnosis was  pleuritis  and  per- 
icarditis. F.  oz.  xvj  purulent 
serum  flowed,  but  autopsy 
showed  it  had  come  from  per- 
icardium, and  that  pleura 
was  adherent.  Eeporter 
says  that  death  must  not  be 
attributed  to  the  tapping. 

At  first  no  fluid,  then  blood 
and  serum,  followed  by  pure 
blood,  apparently  venous, 
andnotinjets.  200 grammes. 
Child  became  pale.  Im- 
provement followed.  Peri- 
carditis did  not  return.  Death 
occurred  five  months  after 
operation.  Author  says  the 
right  ventricle  was  wounded. 

First  tapped  left  jileura,  then 
aspirated  pericardium,  and 
withdrew  025  grammes  se- 
rum. Ten  days  later  aspi- 
rated pleura  again,  and  in- 
jected iodine.  Sputa  like 
phthisis. 

•noT'j'BJado  sq? 
psAiAans  1U9H 
-TJi    ?Bq}    8U1II 

1 
•a 

•q^BBQ 

f-l                                                                                                               IH 

■jfjsAooaa 

iH                                                                                        iH 

.■id 

CQ  o 

1 

Aspiration.         Too 
much   oedema  to 
count  ribs. 

Trocar.    5th   inter- 
space, four   centi- 
metres      outside 
nipple. 

Aspiration.    6th  in- 
terspape. 

Aspiration. 

•83v  puB  xeg 

a           a                 a                   a 

1870 
1872 

o 

H 

a 

Ok 

O 

33,  Ponroy(Fr6my). 

34,  Labric. 

35,  Boger. 

36,  Ghaillou. 

90 


PARACENTESIS  OF  THE  PERICARDIUM. 


i 

is 

H 

as 

■Sa-s 

go's   '' 

Edinburgh  Medical 
Journal,  Oct.  1872, 
p.  376. 

Bulletin  de  I'Acade- 
mie  do  Mfidecine, 
1872,  tome  xxxvii. 
p.  IMl. 

Edinburgh  Medical 
Journal,  June,  1872. 

Practitioner,  xi.  265. 

Edinburgh  Medical 
Journal,  March, 
1875,  p.  799. 

British  Medical  Jour- 
nal, June  19, 1875. 

Lancet,  Aug.  22, 1874, 

p.  271. 
Lancet,  December  19, 

1874. 

0 

"S, 

6 

"3.2   . 
o 

Diarrhoea 
and 
phthisis. 

Pleurisy. 

Plithisisand 
tubercular 
peritonitis. 

Pleurisy  and 
abscess  of 
lung. 
Peritonitis. 

First   tapping,  3  ounces   pus. 
Second    operation,  two  days 
after,  %]/,  ounces  pus.    Left 
canula   in  sac,  and  washed 
out  with  salt  solution.    Died 
with     cerebral     symptoms. 
Followed  pneumonia  of  left 
side. 

1000  grammes  serum.  Tapped 
pleura  1430  grammes.  Died 
in  forty-nine  days  of  diar- 
rhtt'a  and  phtlii.^is. 

Removed  f.  oz.  xxxv. 

Tapped  pericardium  twice, 
f.  oz.  iij^ii  and  f.  oz.  vj.  Last 
time  in  4th  interspace. 
Tapped  abdomen  twice. 

Removed  pus  f.  oz.  xxx  ;  prob- 
ably from  rupture  of  pulmo- 
nary abscess. 

Tapped  six  times.  Purulent 
fluid.  F.  oz.  xxj  ;  f.  oz.  xxxv ; 
f.  oz.  Ix — iodine  injected ;  f. 
oz.  1 — iodine ;  f.  oz.  xxx ;  f.  oz. 
XX  (?) — iodine. 

Acute  rheumatic  pericarditis, 
oz.  X. 

Acute  iheumatic  pericarditis. 
Removed  f.  oz.  xiv.  Walking 
about  in  twenty-seven  days. 

■uoi^BJsdo  eq^ 
paAiAjns  inajt 
-ua    ?T!qi    81UJX 

1 

§ 

1 

49  days. 

6  days. 

50  days. 

Few  hours. 
38  days. 

•q}B3a 

^            ^                 r.       r.                 ^            ^ 

•jCjaAOoaa 

I-(        1H 

■§1 
a 

Thiersch's    syringe 
at    first.       (Aspi- 
ration.)      Trocar 
second  operation. 
Site  not  given. 

Aspiration.    5th  in- 
terspace. 

Incision  and  trocar. 

5th  interspace. 
Aspiration.    3d  and 

4th  interspaces. 

Aspiration.    4th  in- 
terspace. 

Aspiration.    5th  in- 
terspace. 

Aspiration.  4th  in- 
terspace. 

Aspiration.  4th  in- 
terspace. 

•8Sy  puB  X8S 

a 

a 

M.  23 

M.  27 
M.    6 

M.  13 
M.  13 

M.  25 
M.  20 

1 
0 

fH 

1872 

1872 
1873 

1874 

1874 

1874 

1874 

g 

M 
B. 

o 

1 

3 
1-5 

i 

a 
fi 
oo* 

CO 

39,  Chairou. 

40,  Maclaren. 

41,  Heath. 

42,  Saundby. 

43,  Gooch. 

44,  Steele. 

45,  Bartleet. 

TABLE   OF  CASES. 


91 


a 
o 

S5 

a 
a 
a 

a 
K 

Dublin  Journal  of 
Medical  Sciences, 
June  1,  1870. 

London  Mod.  Kecord, 
Sept.  15, 1875,  p.  532; 
from  Marseille  Me- 
dical. 

Gaz.    des     Hopitaux, 
1873,  p.  1130. 

Glasgow          Medical 
Journal,  July,  1877, 
p.  301. 
New  York   Med.  Rec- 
ord, April   1,  1870, 
J).  221 ;    from    Med. 
Comm.  of  Connecti- 
cut Med.  Soc,  1875. 

a 
o 

"H. 
-       I 

6 

a 
Pa 

Left  plouri- 
tis  0  weeks 
previously ; 
endocar- 
ditis. 

Pneumonia 
and  pleu- 
risy. 

Pneumonia. 

o 

■3 
<S 
> 

Two  syringofuls  of  serum. 
Puncture  did  not  close,  fluid 
became  purulent,  and  flowed 
for  nearly  six  months.  Fi- 
nally closed  spontaneously. 

Taliped  eight  times  at  same 
place.  Serous  ett'usion  be- 
coming hemorrhagic.  Two 
punctures  of  the  heart  with- 
out accidents.  Death  fol- 
lowed 3  days  after  eighth  op- 
eration. Intervals  between 
the  operations  wore  4  days,  3 
days,  3  ilays,  4  days,  7  days,  7 
days,  3  days.  Autopsy  showed 
noai-ly  800  grammes  of  choc- 
olate-colored fluid  in  jiericar- 
dium.  No  syncope  or  aggra- 
vation seemed  to  follow  the 
punctures  of  tlie  heart, 
though  80  grammes  and  30 
grammes  of  blood  wore  with- 
drawn. 

Tapped  three  times.  Oz.  xx  se- 
rum ;  15  days  later,  oz.  xxx ; 
11  days  subsequently,  oz.  xv. 

Tapped  twice  at  interval  of  7 
days.  Oz.  xxxii  and  oz.  iss 
pus. 

i 

-a 

1 

29  days. 
9  days. 

•ti^Bsa 

iH 

i-l 

iH             r-l 

•.fa9A008a 

IH 

K 

a'  »■ 

.2  S 

If 
< 

Aspiration.        Most 
projecting  point. 

Aspiration.    5th  in- 
terspace. 

Aspiration.    5th  in- 
terspace. 

Trocar.    5th    inter- 
space. 

•eSy  pnB  xag 

^ 

a                 S 

M.  23 
M.  31 

i 
4 

o 

CO 

p-t 

1873 
1873 

1874 
1874 

i 

O 

a' 
o 

o" 
•* 

47,  Villcueuve. 

48,  Bouchut. 

49,  Maclood. 

50,  Lyon. 

92 


PARACENTESIS  OF  THE  PERICARDIUM. 


o 

a 

H 

a 
P5 

London  Med.  Record, 
iii.  p.  275 ;    from  Gi- 
ornale    Veneto    di 
Scienze      Mediche, 

1875. 

Trans.  State  Med.  So- 
ciety of  Aikansas, 
1875-76;  quoted  in 
American  Journal 
of  Med.  Sciences, 
January,  1877,  p. 
190. 

Lancet,  January  8, 
1875,  p.  50;  Trans. 
Bristol  (England) 
Med.  Chirurg.  Soci- 
ety, vol.i.,  1878,  p.  75. 

New    York     Medical 
Record,      February 
12, 1876,  p.  110. 

L'Union  M^dicale,  25 
rev.,  1879,  p.  315. 

g 

H 

■p. 

1 
6 

•E-3 

|i 

Pleuritis 
when  at- 
tack   be- 
gan?; 

Chronic 
cardiac 
disease. 

Pleurisy. 

Right  pneu- 
monia. 

Paracentesis  of  chest  twice,  and 
abdomen    once,   previously. 
Oz.  X  fluid  from  pericardium. 
Subsequently  pleura  tapped 

again. 

Oz.  xxviii  pus.  Great  relief. 
Respirations  fell  from  60  to 
28.  Patient  was  so  much  ex- 
hausted the  operator  did  not 
operate  a  second  time, 
though  he  considered  the 
question. 

Oz.  xlii  serum.  Left  hospital  in 
ten  weeks  greatly  improved. 
Several  months  later  was  in 
hospital  again  with  cardiac 
symptoms,  but  there  was  no 
indication  of  fluid  in  the  per- 

icardium. 

Oz.  xxx  pus.  After  death  found 
oz.  xxxvi  in  pericardium. 
Pericardial  effusion  probably 
developed  by  admission  of 
pleuritic  effusion  through  a 
minute  opening. 

Tapped  twice.  Pus  43  grammes. 
Next  day  used  laige  trocar 
and  pump  because  fluid  so 
thick.  Pus  and  clots  140 
grammes.  Left  canula  in 
place,  intending  to  inject 
iodine,  but  did  not  do  so. 

psAiAjns  ?nsn 

1 

1 

lO 

22  hours. 

•q^Baa 

IH 

Hi 

IH                                                T-t 

•jCjBAOoaa 

rH 

o 
m  5 

i* 

1 

i. 

o  a) 

+^   C3 

•3   & 

a  S 
a  a 

O  — ' 

is  5 

M 

Aspiration.    4th  in- 
terspace. 

Aspiration.    5th  in- 
terspace. 

Aspiration. 

Aspiration.    4th  in- 
terspace ;  2d  oper- 
ation   trocar,  4th 
interspace. 

•BSy  pnB  X9S 

M.  45 
M.  60 

—  13 

M.  22 

i 

00 

I-l 

1875 
1875 

1875? 
1876 

OS 

o 

-1 

H 

o 

a 

o 

52,  Welch. 

53,  Elliott  (Burder). 

54,  J.  Lewis  Smith  ? 

55,  Viiy. 

TABLE   OF   CASES. 


93 


a 
a 
a 

a 

■p 

Medical  News  and  Li- 
brary, March,  1878, 
and  Ameri<-an  Jour- 
nal of  Med.  Sciences, 
April,  1879. 

Trans.  Detroit    Medi- 
cal and  Library  As- 
sociation, January, 
1879. 

New    York     Medical 
Record,  July,  1878, 
p.  45.     Letter  from 
operator. 

Letter  from  operator. 

a 

% 

a 
5 

1^ 

a  > 
2<2 

Albuminuria 
and   casts ; 
due  to  eS'u- 
sion  in  per- 
icardium. 

Pulmonar;' 
disease  ? 

Pleuritis 
and  ana- 
sarca. 

Hypertrophy 
of  heart. 

•< 

Few  drachms.   At  autop.sy  per- 
icardium contaiuod   oz.  .\iv. 
Near  puncture  firm  adliesion 
to  heart,  which  may  account 
for  small  amount  of  fluid  ob- 

tamed. 
F.  oz.  viij  serum.    Aide  to  get 
out  of  bed  20  days  after  oper- 
ation.   Pleuritis  and  ascites 
314    months    subsequently. 
Death  occurre<l  15   months 
after     operation.     Autopsy 
showed   complete   adhesion, 
no  valvular  lesion,  fatty  de- 
generation     of     muscular 

structure. 
F.  oz.  liv  pus.    Living  when 
case  reported  30  days  subse- 
quently.   Expectorates  pur- 
ulent   matter,  though    his 
condition  is  far  better  than 

at  operation. 

F.  oz.  i  soro-sanguinolent  fluid. 
Much  relief.  S\ibsequently 
tajiped  right  pleural  cavity 
twice.  Died  several  months 
after  with  general  dropsy. 
0.j  fluid  in  pericardium. 

Fluid  drachm  ss  (?)  Great  re- 
lief; due  probably  to  grad- 
ual escape  offluid  into  tissues 
around  pciricardium. 

1 

1 

1          •iH'Kaa 

- 

- 

1        '^jaAooaa 

iH 

f-< 

IH 

ii 

IS 

a  a 

it 

a 

a  o 
•2  '4 

_a 

•2  § 

■|i 

Hypodermic       syr- 
inge. (Aspiration.) 
4th  or  5th  inter- 
space. 

Hypodermic  needle. 
4th  interspace. 

•say  pu«  xsg 

o 
^ 

•* 
s 

M.50 
M.  22 

Date. 

5 

i-H 

i 

00 

1878 
1879 

Operator. 

a 

a 

o 

1 

US 

i 

To 

o 

69,  Porchor. 

CO,  Comogys  Paul. 

94  PARACENTESIS  OF  THE  PERICARDIUM. 


RESULTS    OF   THE    OPERATION. 

In  preceding  chapters  I  have  considered  the  indications 
for  performing  the  operation  of  paracentesis  of  the  peri- 
cardium, have  discussed  the  various  methods  recom- 
mended, have  given  my  views  as  to  the  claims  of  the 
numerous  points  of  puncture  proposed,  and  have  devoted 
some  space  to  discussing  the  objections  urged  against  the 
procedure.  It  now  remains  to  study  the  table  of  opera- 
tions placed  at  the  beginning  of  this  chapter,  in  order  to 
see  what  are  the  results  that  have  been  obtained,  and  that 
we  may  expect  to  obtain,  from  the  performance  of  para- 
centesis of  the  pericardium. 

In  the  table  there  are  recorded  60  cases  of  the  opera- 
tion.*    Of  these,  there  were 

Males 43 

Females 12 

Sex  not  mentioned  ........       5 

It  may  be  interesting  to  study  the  relation  of  the  oper- 
ation and  the  ages  of  the  patients  so  treated : 

The  cases  under  twenty  years  (inclusive)  numbered       .     20 
"  over  twenty  years  numbered  .         .         .         .25 

"  whose  age  was  not  given  numbered         .         .15 

The  greatest  age  at  which  tapping  was  done  was  sixty- 
eight  years,  and  the  patient  in  this  instance  (No.  28)  was 
a  female,  who  was  operated  upon  twice.  It  is  deemed 
worthy  of  notice  that  this  is  apparently  the  only  time  that 

*  McCall  Anderson  recently  aspirated  the  pericardium  of  a  boy,  aged 
seventeen  years.  Great  improvement  followed;  but  the  report  was  made 
just  after  the  operation,  and  it  is  not  possible  to  state  the  result.  See 
Glasgow  Medical  Journal,  September,  1879,  p.  216. 


RESULTS   OF  THE   OPERATION.  95 

the  puncture  was  made  on  the  right  side  of  the  sternum. 
It  has  previously  been  stated  that  this  side  has  quite 
recently  been  suggested  as  the  most  available  spot.  The 
youngest  patients  were  those  of  Roger  (No.  35)  and  Yil- 
leneuve  (ISTo.  47),  who  were  five  years  of  age. 

In  all  branches  of  medicine  the  main  question  that  arises, 
when  a  line  of  action  is  advocated  in  therapeutics,  is  this : 
"What  is  the  ratio  of  recovery  ?  This  query  I  now  attempt 
to  answer : 

The  recoveries  were  .......     24 

"    deaths  were 36 

Total 60 

It  will  be  observed  that  I  have  included  under  the  head- 
ing of  fatal  cases  the  patient  operated  on  by  Jowett  (No.  4), 
where  it  is  stated  that  there  was  a  "  hope  of  recovery." 
This  is  done,  because  I  do  not  wish  the  statistics  to  give  a 
more  favorable  view  than  is  just.  There  are  few  probably 
who  distrust  statistics  as  much  as  I  do,  since  so  much 
depends  on  the  accuracy  and  non-partisanship  of  the 
reporter.  Especially  is  this  the  fact  when  a  man  reports 
a  number  of  cases  occurring  in  his  own  practice.  That 
unknown  quantity,  the  "  personal  equation"  as  to  diag- 
nostic skill,  accuracy,  and  veracity,  satiates,  to  my  mind, 
the  great  majority  of  such  results.  Hence  I  have  endeav- 
ored in  compiling  these  statistics  to  lean  towards  the  side 
of  the  unbeliever,  rather  than  to  make  too  fair  a  showing 
for  my  side  of  the  question. 

Taking,  then,  the  recoveries  as  twenty-four,  and  the 
deaths  at  thirty-six,  we  have  40  per  cent,  as  the  average 
of  recover}',  or  60  percentage  of  mortality.  This  average 
is  certainly  a  good  one,  when  the  almost  always  fatal  re- 
sult of  expectant  treatment  is  remembered.  If  the  fluid 
be  not  evacuated,  the  quantity  increases  until  pressure 


96  PARACENTESIS  OF  THE  PERICARDIUM. 

upon,  and  maceration  of,  the  heart,  as  well  as  the  injurious 
tension  to  which  the  surrounding  intra-thoracic  structures 
are  subjected,  cause  the  death  of  the  patient  after  most 
distressing  symptoms,  with  five  pints*  or  more  of  pus  in 
the  enormously  distended  sac. 

The  mortality  after  tracheotomy  in  croup  in  the  St. 
Eugenie  Hospital  is,  according  to  Barthez,t  about  66|  per 
cent.,  and  the  number  of  cases  that  die  after  herniotomy 
is  certainly  great;  yet  these  operations  are  accepted  as 
justifiable.  Why,  then,  should  one  hesitate  to  tap  the  peri- 
cardium in  large  effusions,  when  the  fatality  of  let-alone 
treatment  is  fully  recognized  ?  The  mortality  of  60  per 
cent,  is  certainly  better  than  that  mentioned  above  as  fol- 
lowing tracheotomy.  A  man  who  would  open  a  child's 
trachea  in  a  trice  for  croup,  would  in  many  cases,  I  fear, 
let  that  child's  father  die  with  pericardial  effusion,  because 
he  dare  not  tap  the  pericardium,  and  thus  remove  the 
agent  preventing  the  proper  oxygenation  of  blood  as  effect- 
ually as  the  membrane  in  the  child's  larynx.  The  mor- 
tality in  paracentesis  pericardii,  given  above,  is  inclusive 
of  all  cases  found  in  the  table,  but  very  many  of  the  pa- 
tients had  serious  diseases  complicating  the  pericardial 
effusion.  Of  the  thirty-six  who  died,  there  were  thirty-one 
who  are  known  by  us  to  have  had  other  concomitant  and 
often  incurable  disease.  In  the  five  remaining  instances 
there  was  no  other  disease,  or  at  least  none  mentioned. 
This  would  give  the  astonishing  result  of  only  five  cases 
of  death  from  uncomplicated  pericardial  effusion  in  a  series 
of  sixty  cases  of  operation. 

Let  us  look,  however,  at  the  results  of  the  operation  in 
recent  times  only,  for  the  earlier  cases  cannot  be  scruti- 

*  Boston  Medical  and  Surgical  Journal,  February,  1866,  p.  29. 
f  Atkin's  Practice  of  Medicine,  2d  American  ed.,  vol.  ii.  p.  998. 


RESULTS   OF  THE   OPERATION.  97 

nized  witli  as  miicli  tlioroiighness  as  desirable,  and,  more- 
over, do  not  give  as  minute  details  as  I  wisli  to  obtain. 
To  avoid  tlie  influence  of  sucli  cases  as  Romero's,  Kyber's, 
Aran's,  and  Beliier's,  whose  authenticity  has  been  ques- 
tioned and  cannot  be  absolutely  proved  at  this  period,  I 
shall  take  the  cases  that  have  occurred  since  1860.  In 
this  number  I  include  the  fatal  cases  of  Chaillou  and  La- 
bric,  whose  dates  I  have  not  obtained,  since  it  is  probable 
that  the  operation  was  performed  after  1860.  The  record 
will  then  stand  as  follows  : 

Since  18G0  there  have  been    .         .         .         .10  recoveries. 
"  ""....     25  deaths. 

Total 35  cases. 

This  gives  a  mortality  of  71.42-f  per  cent.  In  the  tw^enty- 
five  instances  where  death  occurred  subsequent  to  the 
tapping,  serious  disease  is  stated  to  have  existed  in  all 
the  cases  except  three  (Nos.  31,  34,  and  38).  In  other 
words,  out  of  the  whole  thirty-five  cases  operated  upon, 
there  were  thirteen  cases  of  pericardial  effusion  where 
other  diseases  did  not  seem  to  act  as  a  complication,  and 
of  these  ten  recovered  and  three  died.  This  would  give  a 
mortality  of  23+  per  centum. 

By  looking  over  the  whole  table  it  will  be  seen,  as 
stated  on  page  79,  that  the  average  time  of  survival  of 
those  who  are  known  to  have  lived  beyond  the  first  day  is 
over  twenty-seven  days,  which  is  equivalent  to  the  asser- 
tion that  those  who  are  not  actually  moribund,  and  who 
survive  the  shock  of  operation,  have  a  probable  prolonga- 
tion of  life  of  nearly  four  weeks. 

Thus,  then,  I  have  gleaned  from  the  long  list  of  cases 
the  facts  seeming  to  me  most  important,  and  by  elimi- 
nating disturbing  factors  have  presented  a  statement  meant 
to  be  impartial.     I  am  undoubtedly  an  advocate  of  the 


98  PARACENTESIS  OF  THE  PERICARDIUM. 

operation  in  selected  cases,  and  may  have  unconsciously 
misrepresented  the  views  of  others,  or  unduly  assumed 
that  my  side  of  the  question  was  the  correct  one.  If  I 
have  done  so,  I  must  regret  it,  for  no  scientific  progress  is 
to  be  expected  until  writers  step  outside  of  self  and  weigh 
pro's  and  con's  with  an  assayer's  balance. 

Surely  the  record  I  have  given  supports  the  plea  for  the 
adoption  of  paracentesis  of  the  pericardium  into  the  family 
of  accepted  surgical  procedures ;  surely  it  is  noble  to  add 
three  or  four  weeks  to  the  life  of  a  fellow-being.  What 
care  I  if  you  call  it  a  palliative  operation,  forsooth  !  Do 
we  not  excise  carcinomatous  breasts  ?  Does  not  every  one 
tap  ascitic  bellies,  when  cirrhotic  liver  exists,  for  pallia- 
tion ?  Would  you  withhold  opium  from  a  groaning  pa- 
tient because  it  did  not  extirpate  the  disease  ?  Who  is  to 
estimate  the  value  of  one  week  added  to  the  life  of  a  Csesar? 
A  perfect  hip-joint  is  not  expected  after  chronic  coxitis, 
neither  must  a  perfect  heart  be  looked  for  after  chronic 
pericarditis.  Let  the  operation  be  palliative,  if  you  will; 
but  operate,  and  that  before  continuance  of  inflammation, 
maceration  of  the  heart,  and  pressure  of  the  distended  sac 
have  caused  the  tissues  to  assume  pathological  aspects  of 
such  a  kind  that  a  perfect  return  of  function  is  impossible. 


IISTDEX. 


Adhesion,  pericardial,  79. 
Anatomy  of  parts  concerned,  40. 
Apex  beat,  position  of,  21. 
Area  of  dulness,  24. 
Artery,  internal  mammary,  71. 
Aspiration,  advantages  of,  49. 
Aspirator,  best  form  of,  53. 
Auscultation  a  means  of  diagnosis,  28. 

B. 

Bright's  disease  a  result  of  effusion,  46. 
Bulging  a  sign,  20. 


Capacity  of  normal  pericardium,  15. 
Causes  of  pericardial  effusion,  9. 
Complications,  82. 
Complications,  treatment  of,  82. 

D. 

Dangers  to  be  encountered,  71. 
Death  after  operation,  case  of,  75. 
Deaths,  95. 
Diagnosis,  29. 
Diagnosis,  errors  of,  30,  33. 
Dilatation,  diagnosis  of,  31, 
Drainage  in  pericarditis,  56. 
Dulness,  area  of,  24. 
Dulness,  factors  producing,  23. 
Dulness  in  fifth  right  interspace,  23. 
Dulness,  Botch's  experiments  on,  25. 
Dulness,  triangular,  25. 


Effusion  becoming  purulent,  80. 
Effusion,  post-mortem,  9. 


Fistula,  pericardial,  83. 
Fitch's  trocar,  50. 
Friction  sound,  28. 

H. 

Hfemo-pericardium,  16. 
Heart,  wound  of,  73. 
Heart,  wound  of  (cases),  73. 
Hemorrhagic  effusion,  13. 
History  of  paracentesis,  38. 
Hydro-pericardium,  34. 
Hypertrophy,  diagnosis  of,  30,  32. 

I. 

IiI?pection  a  means  of  diagnosis,  20. 

Internal  mammary  artery,  71. 

Internal  mammary  artery,  hemorrhage 
from,  72. 

Intra-thoracic  growths  a  cause  of  peri- 
carditis, 12. 

Iodine,  injection  of,  54. 

K. 

Kidney  disease  a  complication,  46. 


M. 


Method  of  operating,  best,  67. 
Methods  of  operating,  49. 


99 


100 


INDEX. 


Mortality,  95. 
Myocarditis,  35. 


N. 


Nomenclature  of  pericardial  eifusions, 

16. 

0. 

Objections  to  the  operation,  77. 
Operating,  best  method  of,  67. 
Operation,  a  palliative,  77. 
Operation,  cases  suitable  for,  44. 
Operation,  repetition  of,  81. 

P. 

Palpation  a  means  of  diagnosis,  21. 
Paracentesis,  death  after,  75. 
Percentage  of  recovery,  95. 
Pepper's  trocar,  52. 
Percussion  a  means  of  diagnosis,  22. 
Pericarditis,  hemorrhagic,  13. 
Pericarditis,  idiopathic,  10. 
Pericarditis,  inflammatory,  10. 
Pericarditis,  purulent,  13. 
Pericarditis,  purulent,  treatment  of,  55. 
Pericarditis,  secondary,  10. 
Pericardium,  anatomy  of,  40. 
Pericardium,  limits  of,  42. 
Physical  signs,  20. 
Pleura,  relations  of,  43. 
Pneumo-hydro-pericarditis,  47. 
Point  of  puncture,  58. 
Point  of  puncture,  best,  66. 
Points  of  puncture  recommended,  59. 
Post-mortem  effusion,  9. 
Precautions,  68. 
Prognosis,  34. 


Quantity  of  fluid,  14. 


R. 

Reaccumulation  of  fluid,  80,  81. 

Recoveries,  95. 

Repetition  of  operation,  81. 

Results,  94. 

Results  since  1860,  96. 

Roberts's  trocar,  51. 

Rotch's  experiments,  25. 


Secondary  operations,  81. 
Signs,  physical,  20. 
Statistics,  94. 
Statistics  since  1860,  96. 
Suitable  cases,  44. 
Survival,  time  of,  78. 
Symptoms,  objective,  18. 
Symptoms,  subjective,  17. 


Table  of  cases,  84. 
Time  of  operation,  48. 
Treatment,  medical,  36. 
Treatment,  surgical,  49. 
Treatment  of  complications,  82. 
Trephining  the  sternum,  49. 
Triangular  area  of  dulness,  25. 
Trocar,  Fitch's,  50. 
Trocar,  Pepper's,  52. 
Trocar,  Roberts's,  51. 


Varieties  of  fluid  eifused,  12. 
Venous  pulsation  a  symptom,  19. 

W. 

Wound  of  heart,  73. 
Wound  of  heart,  cases  of,  73. 


Tl'R 


>^a= 


COLUMBIA  UNIVERSITY  LIBRARIES  (tisl.stx) 

RD  536  R54  C.1 

Paracentesis  of  the  pencardjunv 


2002245841 


